Not just dryness

Vulvo-vaginal atrophy results from oestrogen loss and is often associated with various complaints in menopausal women.

THE ovaries produce the female hormones, oestrogen and progesterone, during reproductive life. These hormones exert their effects on multiple sites, including the urogenital tract.
There are numerous oestrogen receptors in the vulva, vagina, urethra, bladder and the pelvic floor, and oestrogen maintains the structure and function of the vagina and the surrounding urogenital tissue.

Menopause occurs around 50 years of age, when the ovaries stop producing any more female hormones. This means that women will spend about a third of their lives in the postmenopausal period, a state in which there is little or no oestrogen (hypoestrogenic).

During this time, the oestrogen receptors in the urogenital tract and pelvis also decline.
The hypoestrogenic state results in a loss of elasticity and hydration of the pelvic mucosa.
The vagina becomes less distensible, with shortening and narrowing. The mucosal lining of the vagina, introitus and labia become thin and dry with the decrease in secretions.
With the passage of time, the vaginal mucosa becomes friable and may bleed with minimal trauma like sexual intercourse or even a gynaecological examination.

The thin vagina also leads to a significant reduction of glycogen and a consequent reduction in the population of lactobacilli, resulting in an increase in pH and a decrease of hydrogen peroxide, thereby permitting the growth of pathogenic micro-organisms and increasing susceptibility to infections. There are similar changes in the vulva, urinary tract and pelvic floor. These changes are called vulvo-vaginal atrophy (VVA). In contrast to vasomotor symptoms like hot flushes and sweats, which usually improve over time even without treatment, VVA is chronic and progressive. The severity of its symptoms is variable, ranging from mild discomfort to pain which may reach a point where sexual intercourse is no longer pleasurable or possible.
Women who are not sexually active may be troubled by vaginal dryness and itching, which may worsen with time.

The factors which impact VVA include age, timing and type of menopause, number of births and vaginal deliveries, frequency of sexual intercourse and certain medical conditions and/or medicines. Studies report that the symptoms of VVA like poor lubrication and painful sexual intercourse (dyspareunia) affect 20% to 45% of women in mid-life, with significant impact on a woman’s sexual health and quality of life. However, only a minority seek help or are offered help by their doctors. When managing VVA, a detailed history and physical examination, including a pelvic examination, will be carried out by the doctor. The objective is to identify contributing factors, alternative causes, and therapeutic interventions that have been undertaken.

The physical and pelvic examination would identify physical signs that are consistent with VVA and exclude other pathological conditions that may cause similar symptoms. The primary goal of treating symptomatic VVA is to relieve symptoms. Non-prescription therapies include non-hormonal vaginal lubricants and moisturizers which are available over-the-counter in the pharmacy.

The regular use of non-hormonal, long-acting vaginal moisturizers can decrease vaginal pH to premenopausal levels, although there is no change in the vaginal cells. There are no published reports on the irritative potential of these products. As such, it is advisable to test them on a small patch of skin for 24 hours before inserting them into the vagina. If the product that tests successfully on the skin still causes vaginal irritation, a switch to another product is advisable.
Studies on herbal products like black cohosh, soy and other herbs have not shown any beneficial effect on VVA. The gold standard for the treatment of symptomatic VVA is oestrogen, which can be administered orally or into the vagina. The latter is the preferred mode of delivery when vaginal symptoms are the only complaint. Low-dose vaginal oestrogen provides sufficient oestrogen to relieve symptoms with minimal absorption into the blood stream.

Vaginal oestrogen is more effective than oral oestrogen in relieving VVA symptoms, with 80% to 90% of women reporting a favourable response to the former compared with 75% of women in the latter. The prescription of oestrogen is avoided in certain medical conditions, e.g. breast cancer and venous thromboembolism. Women with symptomatic VVA unrelated to sexual activity are usually prescribed non-hormonal, long-acting vaginal moisturizers and low-dose vaginal oestrogen.

A short course of between one and three months is needed for the woman to become symptom-free. However, symptoms may recur upon cessation of treatment. Women with symptomatic VVA related to sexual activity are managed according to the severity of symptoms.
Initially, non-hormonal vaginal lubricants are used with sexual intercourse together with long-acting vaginal moisturizers regularly. Non-responders to non-hormonal vaginal lubricants and moisturizers would be prescribed low-dose vaginal oestrogen.

Women with moderate to severe dyspareunia who prefer non-vaginal medicines would be prescribed transdermal or oral hormone therapy or ospemifene, a selective oestrogen receptor modulator (SERM). Some women may have vaginal narrowing or spasm, which limits penetration. Gentle stretching with lubricated vaginal dilators of graduated sizes helps in the restoration and subsequent maintenance of function. The re-initiation of regular sexual activity when penetration is again comfortable helps to maintain vaginal health. Pelvic floor physical therapy and the use of vaginal oestrogen prior to vaginal dilatation are also beneficial. VVA is a chronic and progressive condition which is under-reported, under-diagnosed and under-treated.

Patient and physician education about VVA would go a long way towards the maintenance of vaginal and sexual health as well as patients’ quality of life in their golden years.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.