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Urogenital Atrophy

M. P. Brincat, J. Calleja-Agius

Department of Obstetrics and Gynaecology, Mater Dei Hospital, Malta

Atrophic changes of the vulva, vagina and lower urinary tract can have a large impact on the quality of life of menopausal women.  The patient herself may not openly discuss the discomfort that she may be experiencing, especially if related to sexual function.  This may arise from cultural or religious beliefs.  However, hormonal and non-hormonal treatments can provide patients with the solution to regain previous level of function.  Therefore, clinicians should sensitively question and examine menopausal women, in order to correctly identify the pattern of changes in urogenital atrophy and manage appropriately.

Presentation

The classical changes in an atrophic vulva include loss of labial and vulvar fullness, with narrowing of the introitus and inflamed mucosal surfaces.  This is the most frequent cause of genital complaints in the menopausal woman. The vulva loses collagen, adipose and water-retaining ability.  This leads to loss of turgor, elasticity and pubic hair.

Three of the most common non-neoplastic epithelial disorders of the vulva which can present in the postmenopausal women are lichen sclerosus, lichen planus, and lichen simplex chronicus.

In the menopause, the most prevalent urogenital symptoms are vaginal dryness, vaginal irritation or itching and vaginal discharge. Oestrogen stimulates the maturation of the vaginal epithelium and its production of glycogen.  As oestrogen levels decrease, there is a loss of lactobacilli, thus the vagina becoming more alkaline, allowing for colonization of the vagina by faecal flora and other pathogens.  There is also a change in both quality and quantity of vaginal secretions (1).  With oestrogen loss, the vagina shortens and narrows due to the loss of  elasticity and ruguae, and thinning of its walls.  The vaginal surface becomes friable with petechiae, ulcerations, and bleeding on minimal trauma.

Sexually active women find coital activity uncomfortable because of inadequate lubrication during arousal.  Dyspareunia and vaginal bleeding from fragile atrophic skin are common problems, which can occur in up to 30% of postmenopausal women not using hormone replacement therapy (2).  Insertional dyspareunia is thought to occur because of decreased basal levels of vaginal capillary blood flow and oxygen.

Other urogenital complaints include frequency, nocturia, urgency, incontinence and urinary tract infections.  In the lower urinary tract, there is atrophy of the urethral epithelium, with decreased sensitivity of urethral smooth muscle and decreased amount of collagen in periurethral collagen. This leads to the above mentioned symptoms, commonly termed the urethral syndrome. Up to 70% of women relate the onset of urinary incontinence to their final menstrual period, with 20% complaining of severe urgency and almost 50% complaining of stress incontinence. Urge incontinence in particular is more prevalent following the menopause and the prevalence would appear to rise with increasing years of oestrogen deficiency (3).

Management

An individualized management plan is required for menopausal women with urogenital atrophy.  This consists of supportive guidance and counselling regarding vulvar hygiene, with lifestyle modifications such as avoidance of heavily scented products, use of loose-fitting cotton underwear, thoroughly drying the perineal area after bathing and cessation of smoking.    Regular washing with a moisturising cream is often the most helpful for vulval irritation and dryness.

Hormonal therapy is ideally localized to the vagina and given in the lowest dose possible.  This is because systemic oestrogen therapy and high-dose vaginal oestrogen therapies can have a stimulatory effect on the endometrium, possibly resulting in proliferation, hyperplasia or carcinoma.  Local vaginal oestrogen therapy can provide most women with a more effective and faster relief of genitourinary complaints.  Although systemic absorption of oestrogen can occur with local preparations, there is insufficient data to recommend annual endometrial surveillance in asymptomatic women using local oestrogens (4).

For menopausal women experiencing recurrent urinary tract infections and who have no contraindication to local hormone replacement, vaginal oestrogen therapy could be offered. The role of oestrogen replacement therapy in the management of postmenopausal urinary incontinence remains controversial. Oestrogen supplementation subjectively improves urinary stress incontinence but there is no objective benefit when given alone; however, oestrogen given in combination with phenylpropanolamine may be clinically more useful in improving urinary leakage (5). Oestrogen therapy alleviates the irritative symptoms of urinary urgency, frequency, and urge incontinence, although this effect may result from reversal of urogenital atrophy rather than a direct action on the lower urinary tract This e-mail address is being protected from spambots. You need JavaScript enabled to view it </Address><Web_URL>PM:14550837</Web_URL><ZZ_JournalStdAbbrev><f name="System">Urology</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(6).

The role of oestrogen replacement therapy in the treatment of women with recurrent lower urinary tract infections remains to be determined, although there is now some evidence that vaginal administration may be efficacious. Low-dose, vaginally administered oestrogens have a role in the treatment of urogenital atrophy in postmenopausal women and appear to be as effective as systemic preparations This e-mail address is being protected from spambots. You need JavaScript enabled to view it </Address><Web_URL>PM:14550837</Web_URL><ZZ_JournalStdAbbrev><f name="System">Urology</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(7).  However, the 'best' type of oestrogen, route of administration and duration of therapy are at present unknown.

A meta-analysis was carried out to evaluate the efficacy of oestrogen therapy in the treatment of postmenopausal women with symptoms and signs associated with urogenital atrophy. This revealed a statistically significant benefit of oestrogen therapy for all outcomes studied. In 54 uncontrolled case series, the patient symptoms were treated by 24 different treatment modalities. All routes of administration appeared to be effective and maximum benefit was obtained between 1 and 3 months after the start of treatment. As expected, the least systemic absorption of oestrogen was seen with oestriol (administered orally or vaginally), then vaginal oestradiol as measured by pre-therapy and post-therapy serum oestradiol and oestrone (8).

Research has also been carried out using selective oestrogen-receptor modulators (SERMs). In studies using an immature ovariectomized rat model, lasofoxifene, a new SERM, has been shown to be effective in vaginal and vulvar atrophy in postmenopausal women. Lasofoxifene and raloxifene showed a minimal increase in vaginal and uterine weight, epithelial cell proliferation, and epithelial thickness in comparison with oestradiol and tamoxifen. Lasofoxifene significantly enhanced vaginal mucus formation in a dose-dependent manner. These results demonstrated that lasofoxifene stimulated vaginal mucus formation without causing cell proliferation in the rat reproductive tract. These effects may be due to the increased vaginal oestrogen receptor beta and androgen receptor levels. This cellular and molecular profile of lasofoxifene in the vagina may account for its efficacy in the treatment of vaginal and vulvar atrophy in postmenopausal women This e-mail address is being protected from spambots. You need JavaScript enabled to view it </Address><Web_URL>PM:16837883</Web_URL><ZZ_JournalStdAbbrev><f name="System">Menopause.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>(9).

Non-hormonal treatments include bioadhesive vaginal moisturizing gels, polymer gels and water based vaginal lubricants.  These are especially effective for the relief of coital discomfort.  These products are available in a range of preparations, including jelly, gel, moisturizer and warming formulations. Acupuncture, plant estrogens and herbal supplements are also popular among menopausal women.  Soy, chasteberry and ginseng have all been studied for their use in the treatment of postmenopausal vulvovaginal symptoms, however the sources, doses and efficacy are poorly documented, and therefore cannot be recommended as treatment (10).  .

Conclusion: Recommendations

Health-care providers should routinely assess postmenopausal women for the symptoms and signs of vaginal atrophy, a common condition that exerts significant negative effects on quality of life.  Vaginal moisturizers applied on a regular basis have an efficacy equivalent to local hormone replacement for the treatment of local urogenital symptoms such as vaginal itching, irritation, and dyspareunia, and should be offered to women wishing to avoid use of hormone replacement therapy.  Women experiencing vaginal atrophy can be offered any of the following effective vaginal oestrogen replacement therapies: conjugated equine oestrogen cream, a sustained-release intravaginal oestradiol ring, or a low-dose oestradiol tablet.

(1)   Bachmann G, Cheng RJ, Rovner E. Vulvovaginal Complaints. In: Lobo RA, editor. Treatment of the Postmenopausal Woman. Elsevier, 2007: 263-269.

(2)   Bachmann GA, Leiblum SR, Kemmann E, Colburn DW, Swartzman L, Shelden R. Sexual expression and its determinants in the post-menopausal woman. Maturitas 1984; 6(1):19-29.

(3)   D.Robinson, L.Cardozo. Urinary Incontinence. In: D.Keith Edmonds, editor. Dewhurst's Textbook of Obstetrics and Gynaecology. Blackwell Publishing, 2007: 504-559.

(4)   Johnston SL, Farrell SA, Bouchard C, Farrell SA, Beckerson LA, Comeau M et al. The detection and management of vaginal atrophy. J Obstet Gynaecol Can 2004; 26(5):503-515.

(5)   Hextall A, Cardozo L. The role of estrogen supplementation in lower urinary tract dysfunction. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12(4):258-261.

(6)   Robinson D, Cardozo LD. The role of estrogens in female lower urinary tract dysfunction. Urology 2003; 62(4 Suppl 1):45-51.

(7)   Robinson D, Cardozo LD. The role of estrogens in female lower urinary tract dysfunction. Urology 2003; 62(4 Suppl 1):45-51.

(8)   Cardozo L, Bachmann G, McClish D, Fonda D, Birgerson L. Meta-analysis of estrogen therapy in the management of urogenital atrophy in postmenopausal women: second report of the Hormones and Urogenital Therapy Committee. Obstet Gynecol 1998; 92(4 Pt 2):722-727.

(9)   Wang XN, Simmons HA, Salatto CT, Cosgrove PG, Thompson DD. Lasofoxifene enhances vaginal mucus formation without causing hypertrophy and increases estrogen receptor beta and androgen receptor in rats. Menopause 2006; 13(4):609-620.

(10)   ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists. Use of botanicals for management of menopausal symptoms. Obstet Gynecol 2001; 97(6):suppl-11.