II. Epidemiology

  1. Prevalence: 50% of post-menopausal women within first 3 years

III. Causes

  1. Menopause (most common)
    1. Vulvovaginal Atrophy and dryness symptomatic in 50% of postmenopausal women (due to low Estrogen)
    2. Only 25% of symptomatic women seek medical care
  2. Antiestrogen medications (e.g. Raloxifene, Tamoxifen, GnRH Agonists)
  3. Premature Ovarian Failure
  4. Breast Feeding women
  5. Central Amenorrhea

IV. Pathophysiology

  1. Related to decreased Estrogen with Menopause
  2. Vaginal effects
    1. Vaginal epithelium thins with decreased lubrication
    2. Vaginal canal narrowing
      1. Bleeding or pain on intercourse
    3. Vulvar mucosa thinning
      1. Vulvar burning or irritation
      2. Dyspareunia due to introitus narrowing
    4. Glycogen loss with altered Vaginal pH and flora

V. Symptoms

  1. Vaginal Dryness
  2. Vaginal or vulvar burning, itching or irritation
  3. Dyspareunia
  4. Vaginal Discharge
  5. Urinary urgency
  6. Urge Incontinence

VI. Signs

  1. Vaginal Discharge that is thin or clear
  2. Vaginal introitus narrowing
  3. Loss of labia minora
  4. Vaginal mucosa changes
    1. Mucosa is thin, pale and dry with reduced elasticity
    2. Vaginal rugae lost
    3. Mucosa may be irritated and friable

VII. Labs

  1. Vaginal pH 5 to 7

VIII. Complications

IX. Management: Primary

  1. See Menopause
  2. Symptomatic measures (first-line for mild symptoms)
    1. Vaginal Moisturizers (Replens) applied three times weekly
    2. Vaginal Lubricant (e.g. Astroglide) applied before intercourse
  3. Topical Vaginal Estrogen (second-line for moderate symptoms)
    1. See Vaginal Estrogen
    2. Does not require systemic Progesterone (in intact Uterus) if used <1 year
    3. Low dose Topical Estrogen (e.g. Vagifem, Estring, Estrace or Premarin vaginal cream)
    4. Reduces risk of Recurrent Urinary Tract Infection
    5. Suckling (2006) Cochrane Database Syst Rev (4): CD001500 [PubMed]
  4. Systemic Estrogens (third-line for refractory symptoms, especially Vasomotor Symptoms of Menopause)
    1. See Vasomotor Symptoms of Menopause
    2. Precautions
      1. Do not use Unopposed Estrogen with intact Uterus (requires concurrent Progesterone)
      2. Avoid systemic Estrogens for isolated, localized vaginal symptoms
    3. Continuous Estrogen Replacement
    4. Sequential Estrogen Replacement
    5. Transdermal Estrogen Replacement
    6. Higher dose Topical Estrogen (e.g. FemRing)
      1. Requires Progesterone (in intact Uterus), unlike low dose Topical Estrogens

X. Management: Refractory Symptoms (or unable to use Estrogens)

  1. Intravaginal Prasterone (Intrarosa, synthetic DHEA or Dehydroepiandrosterone)
    1. Vaginal Dehydroepiadrosterone that increases epithelial thickness and decreases Dyspareunia
    2. Indicated in Dyspareunia and moderate to severe Vulvovaginal Atrophy
    3. Although marketed as non-Estrogen, it is DHEA which converts to Estrogens and androgens in vaginal tissue
    4. Expensive (>$200/month)
  2. Osphena (Ospemifene)
    1. Selective Estrogen receptor modifier (SERM) with Vaginal Estrogenic effect (unlike Raloxifene and Tamoxifen)
    2. FDA-approved for severe Dyspareunia
    3. Risk of venous thrombosis and Hot Flashes (similar to Raloxifene and Tamoxifen)
    4. Expensive (> $200/month) with limited indications beyond other measures
    5. Dose: 60 mg once daily with food
    6. (2013) Prescr Lett 20(6):33
  3. Fractional Carbon-Dioxide Laser Therapy
    1. Results in microabrasions that promote increased Blood Flow and thicken vaginal tissue
    2. Decreases Dyspareunia
    3. Similar efficacy to Vaginal Estrogens, but not FDA approved and risk of burns and scarring
      1. https://www.fda.gov/medical-devices/safety-communications/fda-warns-against-use-energy-based-devices-perform-vaginal-rejuvenation-or-vaginal-cosmetic
      2. Paralso (2020) Menopause 27(1):50-6 [PubMed]

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