Question

    Atrophic Vaginitis

    Atrophic Vaginitis originates from the following process: degenerative.

    Presentation

    The following are the various signs and symptoms of atrophic vaginitis:

    • Vaginal dryness
    • Increased urination [4]
    • Itching accompanied by burning sensation in the vagina
    • Urinary tract infections
    • Pain during intercourse due to decreased lubrication and vaginal dryness [5]
    • Vaginal canal gets shortened and tightened

    urogenital
    Dysuria
    • Urinary tract symptoms include dysuria, urinary frequency, urethral discomfort, or, infrequently, hematuria.[uptodate.com]
    • Estrogen replacement therapy has been shown to alleviate urgency, urge incontinence, frequency, nocturia, dysuria (discomfort on passing urine) and reduce urine infections.[womens-health-concern.org]
    • […] vulval dryness Vaginal or vulval itching ( pruritus vulvae ) Vaginal burning Painful sex ( dyspareunia ) Skin splitting (fissuring) of the entrance to the vagina ( posterior fourchette) Vaginal spotting (bleeding) Deficiency of oestrogen may also lead to dysuria[dermnetnz.org]
    • I- History : of -Frequency of urine, dysuria, nocturia, hematuria and incontinence.[slideshare.net]
    • Itching Burning Dyspareunia - Painful Sex Burning leukorrhea Pruritis Vulvae Feeling of pressure Yellow malodorous vaginal discharge Urinary :- Dysuria Urinary Frequency Nocturia - Bladder emptying at night Cystitis Urinary tract infection Urinary Stress[2womenshealth.com]
    Postcoital Bleeding
    • Postcoital bleeding may occur in menopausal or postmenopausal women with atrophic vaginitis because the vagina is not adequately lubricated due to reduced mucosal secretions.[fastbleep.com]
    • The spectrum of adverse consequences makes long-term treatment essential in many women, not only for relief of symptoms, but also for the more troublesome problems that may occur, such as sexual dysfunction, postcoital bleeding, and recurrent urinary[uptodate.com]
    • Vaginal bleeding or postcoital bleeding.[patient.info]
    Sexual Dysfunction
    • The spectrum of adverse consequences makes long-term treatment essential in many women, not only for relief of symptoms, but also for the more troublesome problems that may occur, such as sexual dysfunction, postcoital bleeding, and recurrent urinary[uptodate.com]
    • As a result, menopausal women frequently experience a variety of symptoms such as hot flushes, sleep and mood disorders, weight gain and sexual dysfunction.[dx.doi.org]
    • Over time, the lack of vaginal lubrication often results in sexual dysfunction and associated emotional distress.[aafp.org]
    Vaginal Bleeding
    • When To Call A Professional Schedule an appointment with your doctor if you experience any vaginal bleeding, vaginal dryness, burning or itching, or if painful sexual intercourse is not relieved with a water-soluble lubricant.[drugs.com]
    • Vaginal bleeding or postcoital bleeding.[patient.info]
    • Vaginal estrogen may have the following rare side effects: vulvar itching or irritation, vaginal discharge, and vaginal bleeding; however, a switch to a different dosage or preparation may reduce or eliminate these problems.[mmgyn.com]
    • You should also see your doctor if you experience unusual vaginal bleeding, discharge, burning, or soreness.[healthline.com]
    • Contraindications of local estrogen Unexplained vaginal bleeding Pregnancy Estrogen-sensitive tumors, End-stage liver failure and Past history of estrogen-related thromboembolization. www.freelivedoctor.com 21.[slideshare.net]
    Vaginal Discharge
    • Symptoms of Vaginitis Profuse vaginal discharge.[wgurology.com]
    • Women with atrophic vaginitis may also experience vaginal itching, burning, frequent urination, or vaginal discharge.[health.harvard.edu]
    • Those symptoms may include: vaginal dryness, painful intercourse, vaginal itching, and abnormal vaginal discharge.[mmgyn.com]
    • Cervical inflammation suggests cervicitis contributing to vaginal discharge.[clevelandclinicmeded.com]
    • Symptoms include vaginal discharge, irritation, pruritus, and erythema.[merckmanuals.com]
    Vaginal Dryness
    Vulvar Pain
  • more...
  • Workup

    Diagnosis of the condition starts with a medical history of the patient. Medical history would include information regarding medications, past surgical procedures and diseases if any. In addition, the following methods would be employed for diagnosing atrophic vaginitis:

    • Pelvic examination to check for the signs of vaginal dryness [6]. A visual examination of the vagina is also necessary. An examination for vaginal prolapsed would also be required.
    • Urinary examination to detect signs of infection.
    • Acid balance test is done to examine the vagina for the acid balance. The vaginal fluids are taken for the test or an indicative strip is placed in the vagina for examination. Atrophic vaginitis secretion will present with acidic pH in the tests [7]. 
    • Pelvic ultrasound can demonstrate the diminished endometrial thickness with atrophic vaginitis [8].

    Treatment

    Lubricants and drugs often form the first line of treatment for atrophic vaginitis. The following are various topical agents and lubricants suggested for treating vaginal dryness:

    • Water based lubricants and vaginal moisturizers with vitamin E are advised to improve lubrication [9]. If these work then, topical agents would not be necessary. However these only help improve the dryness, but are not very effective in treating the burning and irritation caused due to the condition. Topical creams may also be applied to relieve pruritus [10].
    • Vaginal estrogen is very effective as it provides controlled release of estrogen to the vagina. Vaginal estrogen is available in various forms such as estrogen creams, estrogen rings and estrogen tablets. Estrogen rings are basically soft flexible rings containing the hormone inserted into the upper part of the vagina. Many women benefit from this method. In the beginning, any one of these therapies is advised on regular basis, and after the first few weeks, weekly application is necessary.

    Prognosis

    The prognosis of the condition is favorable if women seek treatment. With hormone replacement therapy and lubricating agents women often experience less discomfort.

    Complications

    Atrophic vaginitis if not treated on time can cause the following complications:

    • Urinary problems such as increased frequency of urination or burning sensation while urinating can be experienced. This is so because atrophic vaginitis contributes significantly to genitourinary atrophy giving rise to several urinary problems. In addition, women may also complain of incontinence or urinary tract infections.
    • Vaginal infections are the second most common complication of atrophic vaginitis. Decreased production of estrogen disrupts the acid base balance making the vagina susceptible to infections.

    Complications

    Postmenopausal Atrophic Vaginitis
    • Concepts Disease or Syndrome ( T047 ) ICD9 627.3 ICD10 N95.2 SnomedCT 156054004 , 52441000 English Postmenopausal atrophic vaginitis , Postmenop atrophic vaginitis , postmenopausal atrophic vaginitis , postmenopausal atrophic vaginitis (diagnosis) , Atrophic[fpnotebook.com]
    • 2012 ICD-9-CM Diagnosis Code 627.3 Postmenopausal atrophic vaginitis Short description: Atrophic vaginitis.[icd9data.com]
    • Questions related to N95.2 Postmenopausal atrophic vaginitis The word 'Includes' appears immediately under certain categories to further define, or give examples of, the content of thecategory.[icd10coded.com]
    • Overview Postmenopausal atrophic vaginitis, or vaginal atrophy, is the thinning of the walls of the vagina caused by decreased estrogen levels.[healthline.com]
    • Related Medical Abstracts - Click on the paper title:- Local oestrogen for vaginal atrophy in postmenopausal women. (2006-01) Local estrogen replacement therapy in postmenopausal atrophic vaginitis: efficacy and safety of low dose 17beta-estradiol vaginal[2womenshealth.com]
    Pruritus Vulvae
    • Vaginal or vulval dryness Vaginal or vulval itching ( pruritus vulvae ) Vaginal burning Painful sex ( dyspareunia ) Skin splitting (fissuring) of the entrance to the vagina ( posterior fourchette) Vaginal spotting (bleeding) Deficiency of oestrogen may[dermnetnz.org]
    Vaginal Candidiasis
    • Vaginal candidiasis often manifests with a compatible history and normal pH and negative microscopy.[clevelandclinicmeded.com]
    • candidiasis Vaginal infections more complications...»[rightdiagnosis.com]
    • Candidiasis Bacterial vaginosis Trichomoniasis Contact irritation or reaction to: Perfumes Powders Deodorants Panty liners Perineal pads Soaps Spermicides Lubricants Tight-fitting or synthetic clothing On examination, several signs of vaginal atrophy[aafp.org]
    Vaginismus
    • Physical findings among the women included 68 cases of vaginismus, 1 case of vaginal agenesis, and 6 cases of atrophic vaginitis .[thefreedictionary.com]
    Vaginitis
    • […] of the vaginal canal.[symptoma.com]
    • Vaginal atrophy can also be idiopathic.[en.wikipedia.org]
    • vaginitis , Senile (atrophic) vaginitis , Vaginitis;senile , atrophic vaginitis , Postmenopausal atrophic vaginitis (disorder) , Senile atrophic vaginitis , Senile vaginitis , atrophic; vaginitis, postmenopausal , postmenopausal; atrophic vaginitis ,[fpnotebook.com]
    • Key Topics Covered: Vaginal Atrophy (Atrophic Vaginitis) Overview Vaginal Atrophy (Atrophic Vaginitis) Pipeline Therapeutics Vaginal Atrophy (Atrophic Vaginitis) Therapeutics under Development by Companies Vaginal Atrophy (Atrophic Vaginitis) Late Stage[businesswire.com]
    • Symptoms of atrophic vaginitis include vaginal itching, vaginal discomfort and dyspareunia and can significantly affect women's comfort, sexuality and quality of life.[clinicaltrials.gov]
  • more...
  • Etiology

    Decrease in the production of estrogen levels causes development of atrophic vaginitis. The following are the various factors that are known to decrease the production of the hormone estrogen:

    • After menopause
    • Perimenopause
    • During breast feeding
    • Cancer treatments such as radiation therapy and chemotherapy
    • Removal of ovaries
    • Hormonal treatment for breast cancer
    • Chronic tricyclic antidepressant use [3]

    The condition of atrophic vaginitis is a common one; however not all women in the menopausal stage develop this condition.

    Epidemiology

    It has been estimated that about 20 to 50% of postmenopausal women suffer from atrophic vaginitis. Of these, only 25% seek medical help. The condition is far more common than what has been reported. Women often feel embarrassed and do not report symptoms to their doctor.

    Sex distribution
    Age distribution

    Pathophysiology

    The vaginal epithelium is subject to change during various phases of life. At birth the vagina is rich in glycogen due to estrogen supply from the mother. During childhood phase, the epithelium is thin which then thickens during puberty due to increased production of estrogen.

    A sufficient supply of this hormone keeps the vagina lubricated and also maintains the pH levels 3.5 – 4.5. Such level helps protect the vagina against bacterial infections. When the pH goes beyond this level, the vagina gets susceptible to urinary tract infections. During early years of menopause and post menopause, the ovaries secrete less of estrogen that causes the vagina to get dry and inflamed.

    Prevention

    It is advised that women begin applying lubricants and vaginal estrogens to help prevent the condition from turning severe. In addition, sexual activity has also been known to improve the vaginal elasticity and lubrication. Topical treatments in the form of tablets and creams should also be practiced as this increases the vaginal epithelium proliferation.

    Summary

    Atrophic vaginitis is a common condition affecting majority of the women after menopause. It is a condition characterized by inflammation of the vagina accompanied by dryness and therefore the condition is also known as vaginal dryness. Such a condition arises due to low levels of estrogen, the production of which is significantly reduced once woman reach menopause [1].

    Approximately 50% of women in the menopausal state to develop vaginal dryness [2]. However, breast feeding mothers also complain of vaginal dryness. Simple treatment regimes help in effective management of the condition.

    Patient Information

    Definition

    Atrophic vaginitis is a condition characterized by inflammation of the vagina accompanied by dryness and itching. Decrease in estrogen levels gives rise to such a situation. Such condition is more common in women who are in the menopausal stage. Also, women who have undergone surgery to remove the ovaries also develop atrophic vaginitis

    Cause

    Decrease in the production of estrogen is the major cause that leads to development of atrophic vaginitis. The several factors causing lowered production of estrogen include menopause, cancer treatments, surgical removal of ovaries and lactation.

    Symptoms

    Symptoms of atrophic vaginitis include vaginal dryness, burning sensation, frequent urination, incontinence, and pain during intercourse, vaginal discharge, bleeding during intercourse, decreased lubrication, urinary tract infections and shortening of the vaginal canal.

    Diagnosis

    A thorough physical examination to study the vagina for signs of inflammation and dryness is carried out. In addition, pelvic examination is done to check for pelvic prolapse. The vagina is also tested to check for its acid base balance. Various laboratory tests are also required for analyzing the levels of serum hormone levels. A decrease in the levels of estrogen confirms atrophic vaginitis.

    Treatment

    Treatment of atrophic vaginitis includes application of moisturizing vaginal creams and lubricants to improve the dryness and lubrication. However, estrogen creams would also be required to relieve other symptoms of itching, burning sensation and irritation. These include insertion of estrogen tablets or application of estrogen creams to facilitate a controlled release of estrogen to the organ.

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    References

    1. Bachmann GA, Nevadunsky NS. Diagnosis and treatment of atrophic vaginitis. Am Fam Physician. 2000; 61:3090-3096.
    2. Stenberg A, Heimer G, Ulmsten U, et al. Prevalence of genitourinary and other climacteric symptoms in 61 year old women. Mauritas. 1996; 24:31-36.
    3. Nactigall L. Vaginal estrogen in the controversial patient. Menopause Management. 2006; March/April: 19-22.
    4. Simuniæ V, Banoviæ I, Ciglar S, Jeren L, Paviciæ Baldani D, Sprem M. Local estrogen treatment in patients with urogenital symptoms. Int J Gynaecol Obstet. 2003; 82:187-197.
    5. Goldstein I, Alexander JL. Practical aspects in the management of vaginal atrophy and sexual dysfunction in perimenopausal and postmenopausal women. J Sex Med. 2005; 2:154-165.
    6. Bachmann GA, Ebert GA, Burd ID. Vulvovaginal complaints. In Lobo RA ed. Treatment of the Postmenopausal Woman: Basic and Clinical Aspects. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:195-201.
    7. Semmens JP, Tsai CC, Semmens EC, et al. Effects of estrogen therapy on vaginal physiology during menopause. Obstet Gynecol. 1985; 66:15-18.
    8. Weisberg E, Ayton R, Darling G, et al. Endometrial and vaginal effects of low dose estradiol delivered by vaginal ring or vaginal tablet. Climacteric. 2005; 8:83-92.
    9. North American Menopause Society. The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of the North American Menopause Society. Menopause. 2007; 14:355-369
    10. Sobel JD, Chaim W, Nagappan V, Leaman D. Treatment of vaginitis caused by Candida glabrata: use of topical boric acid and flucytosine. Am J Obstet Gynecol. Nov 2003; 189(5):1297-300.

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    • Diagnosis and treatment of atrophic vaginitis - GA Bachmann, NS Nevadunsky - American family , 2000 - ecosistemavaginale.it
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    • Caution: vaginal estradiol appears to be contraindicated in postmenopausal women on adjuvant aromatase inhibitors - A Kendall, M Dowsett, E Folkerd - Annals of oncology, 2006 - Eur Soc Med Oncology
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    • Atrophic vaginitis - T Pearson - The Journal for Nurse Practitioners, 2011 - Elsevier
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