Atrophic vaginitis under diagnosed and under treated Dr.MANINDER AHUJA FARIDABAD  CHAIR PERSON GERIATRIC GYNAECOLOGY COMMI...
What has changed <ul><li>Women have to spend more than 1/3 rd of their life in menopause </li></ul><ul><li>More stress on ...
Menopause – The Emerging Clinical Scenario in India <ul><li>Increased life expectancy has led to increase in number of men...
Comparison of world wide postmenopausal  women over the years 05/01/10 maninder ahuja 1990 2030 World wise population 470n...
FOR ALL THESE WOMEN QUALITY OF LIFE IS IMPORTANT !  05/01/10 maninder ahuja
ATROPHIC VAGINITIS  MOST UNDER REPORTED UNDER DIAGNOSED & UNDERTREATED  05/01/10 maninder ahuja
Perception about vagina <ul><li>Women don’t  want to talk about vagina in public </li></ul><ul><li>It is considered a priv...
WOMEN’S PERCEPTION OF VAGINA 05/01/10 maninder ahuja
EPIDEMIOLOGY OF  ATROPHIC VAGINITIS <ul><li>About 80% of postmenopausal women  symptomatic.  </li></ul><ul><li>About 20% p...
05/01/10 maninder ahuja
ROLE OF VAGINAL PH <ul><li>The normal premenopausal vagina has a pH of  3.5-4.5  </li></ul><ul><li>Estrogen stimulates mat...
CONT.– VAGINAL PH <ul><li>Estradiol levels  fall from about  120 ng/L  in perimenopause to  < 20 ng/L  after menopause. </...
What other indicator of vaginal pathology <ul><li>Severity score by pt. complaint </li></ul><ul><li>Itching ,burning, pain...
Vaginal maturation index(VMI) <ul><li>The Vaginal Maturation Index </li></ul><ul><li>(VMI) is a ratio of parabasal,  </li>...
MATURATION VALUE <ul><li>The maturation value (MV) is calculated using the formula: MV = (0 x % of parabasal cells) + (0.5...
IN POSTMENOPUASE <ul><li>The menopausal vagina alterations in the quantity and quality of its vaginal secretions. </li></u...
ATROPHIC VAGINITIS <ul><li>Introitus  contracted.  </li></ul><ul><li>Ph  increases </li></ul><ul><li>The vaginal rugae are...
Symptoms  <ul><li>Itching </li></ul><ul><li>Burning  </li></ul><ul><li>Painful micturition </li></ul><ul><li>Frequency of ...
Estrogen levels and vaginal symptoms 05/01/10 maninder ahuja
Inadequate hormone-dependent vaginal receptivity & seuality  05/01/10 maninder ahuja USE IT OR LOSE IT!
Other causes <ul><li>Prolonged breastfeeding </li></ul><ul><li>Premature ovarian failure </li></ul><ul><li>After ovarian a...
other causes of vaginitis <ul><li>Vaginal infection </li></ul><ul><li>Bacterial vaginosis  (overgrowth of certain vaginal ...
Other causes  <ul><li>Skin conditions </li></ul><ul><li>Certain diseases like diabetes </li></ul><ul><li>Benign and malign...
Atrophic vaginitis is progressive <ul><li>vasomotor symptoms  may decrease over time  </li></ul><ul><li>Atrophic  vaginiti...
Management  <ul><li>ET improves the maturation (thickness)  </li></ul><ul><li>Elasticity of the epithelium increased </li>...
Local estrogens <ul><li>Localized ET is  as effective as systemic ET for treating vaginal atrophy and is associated with f...
Urinary symptoms <ul><li>Local vaginal estrogen therapy affects ERs in urethral mucosa and smooth muscle. </li></ul><ul><l...
Low dose vaginal estrogens are effective <ul><li>Usual dose of estradiol vaginal cream is 100 –400 mcg/day </li></ul><ul><...
05/01/10 maninder ahuja Even when giving sytemic HRT 27% Pts. have atrophic vaginitis so local treatment is preferred.
Vaginal Estrogen Therapy for Postmenopausal Use in the United States   Modified from NAMS. Menopause Practice:  A Clinicia...
Low dose vaginal estrogen and endometrial cancer <ul><li>In the Cochrane review, no cases of endometrial cancer were repor...
Continued <ul><li>Dugal  et al.  compared estradiol vaginal tablets (25 mg 17ß-estradiol) or estriol vagitories (0.5 mg es...
05/01/10 maninder ahuja
Effect on breast? <ul><li>Reports  conflicting regarding breast safety.  </li></ul><ul><li>Rosenberg  et al.  found no ass...
Carry home message <ul><li>Specifically enquire about atrophic vaginitis symptoms </li></ul><ul><li>Counsel regarding the ...
THIS IS NOT END , THIS IS THE BEGINNIG OF OUR EFFORTS FOR QUALITY CARE! 05/01/10 maninder ahuja
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Atrophic vaginitis under treated under diagnosed(f)

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  • DR.MANINDER AHUJA
  • DR.MANINDER AHUJA
  • DR.MANINDER AHUJA
  • DR.MANINDER AHUJA
  • DR.MANINDER AHUJA
  • DR.MANINDER AHUJA
  • DR.MANINDER AHUJA
  • to chemicals in soaps, bubble baths, spermicides, condoms, feminine hygiene sprays, deodorant tampons/pads
  • (eg, inflammatory bowel disease, diabetes mellitus, lupus erythematosus)
  • DR.MANINDER AHUJA
  • DR.MANINDER AHUJA
  • DR.MANINDER AHUJA
  • Atrophic vaginitis under treated under diagnosed(f)

    1. 1. Atrophic vaginitis under diagnosed and under treated Dr.MANINDER AHUJA FARIDABAD CHAIR PERSON GERIATRIC GYNAECOLOGY COMMITTEE OF FOGSI 05/01/10 maninder ahuja
    2. 2. What has changed <ul><li>Women have to spend more than 1/3 rd of their life in menopause </li></ul><ul><li>More stress on quality of life </li></ul><ul><li>Prevention has a central role to play </li></ul><ul><li>Symptomatic relief of menopausal problems with </li></ul><ul><li>shortest period and smallest dosage possible </li></ul><ul><li>Search for newer salts, new dosage schedule </li></ul>05/01/10 maninder ahuja
    3. 3. Menopause – The Emerging Clinical Scenario in India <ul><li>Increased life expectancy has led to increase in number of menopausal females. </li></ul><ul><li>In 2007, the female life expectancy has gone upto 64.5 years </li></ul>
    4. 4. Comparison of world wide postmenopausal women over the years 05/01/10 maninder ahuja 1990 2030 World wise population 470nmillion 1.2 billion Developing countries 40% 24% Developed countries 60% 76%
    5. 5. FOR ALL THESE WOMEN QUALITY OF LIFE IS IMPORTANT ! 05/01/10 maninder ahuja
    6. 6. ATROPHIC VAGINITIS MOST UNDER REPORTED UNDER DIAGNOSED & UNDERTREATED 05/01/10 maninder ahuja
    7. 7. Perception about vagina <ul><li>Women don’t want to talk about vagina in public </li></ul><ul><li>It is considered a private part </li></ul><ul><li>Some want to talk but feel society is not ready for it. </li></ul><ul><li>So on the whole is still hussh hush </li></ul>No don’t talk! 05/01/10 maninder ahuja
    8. 8. WOMEN’S PERCEPTION OF VAGINA 05/01/10 maninder ahuja
    9. 9. EPIDEMIOLOGY OF ATROPHIC VAGINITIS <ul><li>About 80% of postmenopausal women symptomatic. </li></ul><ul><li>About 20% present with atrophic vaginitis symptoms. </li></ul><ul><li>Of those, about 1% to 5% will seek specific treatment for atrophic vaginitis symptoms. </li></ul><ul><li>Many will seek treatment at a relatively advanced age, about 5 to 10 years after menopause. </li></ul><ul><li>The reason, is an age-related increase in the severity of symptoms -- less than 5% among premenopausal women, going up to about 25% of women by 1 year after menopause, and to 50% by years 3 to 5. </li></ul>05/01/10 maninder ahuja
    10. 10. 05/01/10 maninder ahuja
    11. 11. ROLE OF VAGINAL PH <ul><li>The normal premenopausal vagina has a pH of 3.5-4.5 </li></ul><ul><li>Estrogen stimulates maturation of the vaginal epithelium </li></ul><ul><li>Lactobacilli in the vagina metabolize glucose (produced by the breakdown of glycogen) to lactic acid, which is responsible for the acidic nature of the vagina. </li></ul><ul><li>> 5 in a premenopausal woman suggests the presence of a pathologic vaginitis. </li></ul>05/01/10 maninder ahuja
    12. 12. CONT.– VAGINAL PH <ul><li>Estradiol levels fall from about 120 ng/L in perimenopause to < 20 ng/L after menopause. </li></ul><ul><li>This drop in estrogen leads to a decrease in glycogen and lactobacilli, resulting in a shift toward a less healthy alkaline pH </li></ul><ul><li>pH >5 predisposes the vagina to infection by pathogens. </li></ul>05/01/10 maninder ahuja
    13. 13. What other indicator of vaginal pathology <ul><li>Severity score by pt. complaint </li></ul><ul><li>Itching ,burning, painful micturition </li></ul><ul><li>Local exam.of vagina </li></ul><ul><li>Type of discharge. </li></ul><ul><li>Vaginal cytology findings </li></ul><ul><li>(ie,VMI or MV). </li></ul>05/01/10 maninder ahuja
    14. 14. Vaginal maturation index(VMI) <ul><li>The Vaginal Maturation Index </li></ul><ul><li>(VMI) is a ratio of parabasal, </li></ul><ul><li>intermediate, and superficial squamous cells found on a </li></ul><ul><li>cytologic smear of cells from the </li></ul><ul><li>upper third of the vagina. </li></ul><ul><li>The numbers of each type of cell </li></ul><ul><li>in 100 cells from the smear are counted. </li></ul><ul><li>The number of mature squamous cells in estrogen-deficient patients </li></ul><ul><li>is typically low (< 5) , while a </li></ul><ul><li>majority of the cells are basal and </li></ul><ul><li>parabasal </li></ul>05/01/10 maninder ahuja
    15. 15. MATURATION VALUE <ul><li>The maturation value (MV) is calculated using the formula: MV = (0 x % of parabasal cells) + (0.5 x % of intermediate cells) + (1.0 x % of superficial cells). </li></ul><ul><li>With adequate estrogenic stimulation, superficial squamous cells are prevalent (typically > 25). </li></ul>05/01/10 maninder ahuja
    16. 16. IN POSTMENOPUASE <ul><li>The menopausal vagina alterations in the quantity and quality of its vaginal secretions. </li></ul><ul><li>Prior to menopause, women typically produce vaginal fluid that is clear or slightly white in color, odorless, and nonirritating. </li></ul><ul><li>As estrogen levels decline at menopause, vaginal fluid becomes scant and yellowish in color, and lubrication is diminished during sexual activity </li></ul>05/01/10 maninder ahuja
    17. 17. ATROPHIC VAGINITIS <ul><li>Introitus contracted. </li></ul><ul><li>Ph increases </li></ul><ul><li>The vaginal rugae are diminished </li></ul><ul><li>Epithelium has a smooth, dry pale appearance. </li></ul><ul><li>Some petechiae may be there </li></ul><ul><li>Vulvar fat is reduced </li></ul>05/01/10 maninder ahuja
    18. 18. Symptoms <ul><li>Itching </li></ul><ul><li>Burning </li></ul><ul><li>Painful micturition </li></ul><ul><li>Frequency of micturition </li></ul><ul><li>Dysparunia </li></ul><ul><li>Decreased sexual desire </li></ul>05/01/10 maninder ahuja
    19. 19. Estrogen levels and vaginal symptoms 05/01/10 maninder ahuja
    20. 20. Inadequate hormone-dependent vaginal receptivity & seuality 05/01/10 maninder ahuja USE IT OR LOSE IT!
    21. 21. Other causes <ul><li>Prolonged breastfeeding </li></ul><ul><li>Premature ovarian failure </li></ul><ul><li>After ovarian ablation (chemical or radiation induced) </li></ul><ul><li>Hypothalamic amenorrhea or hyperprolactinemia </li></ul><ul><li>Medication to decrease estrogen levels as a treatment for endometriosis or uterine fibroids. </li></ul>05/01/10 maninder ahuja
    22. 22. other causes of vaginitis <ul><li>Vaginal infection </li></ul><ul><li>Bacterial vaginosis (overgrowth of certain vaginal bacteria) </li></ul><ul><li>Sexually transmitted diseases </li></ul><ul><li>Allergic reactions </li></ul><ul><li>Douching </li></ul><ul><li>Irritation from tampons or birth control devices </li></ul><ul><li>Trauma </li></ul><ul><li>Foreign body </li></ul>05/01/10 maninder ahuja
    23. 23. Other causes <ul><li>Skin conditions </li></ul><ul><li>Certain diseases like diabetes </li></ul><ul><li>Benign and malignant tumors </li></ul><ul><li>Psychological causes </li></ul><ul><li>Injury to pelvic nerve fibers, vulvar pain Vulvodynia </li></ul><ul><li>Certain endocrine therapies (eg, aromatase inhibitors) </li></ul><ul><li>Certain medications (eg, antibiotics) </li></ul><ul><li>Medically induced menopause (eg, cancer treatment) </li></ul>05/01/10 maninder ahuja
    24. 24. Atrophic vaginitis is progressive <ul><li>vasomotor symptoms may decrease over time </li></ul><ul><li>Atrophic vaginitis usually persists if left untreated. </li></ul><ul><li>Both estrogen and sexual activity, which promotes blood flow to the genital area, help maintain vaginal health .. </li></ul>05/01/10 maninder ahuja
    25. 25. Management <ul><li>ET improves the maturation (thickness) </li></ul><ul><li>Elasticity of the epithelium increased </li></ul><ul><li>Increases blood flow to the vagina </li></ul><ul><li>Reduces vaginal pH </li></ul><ul><li>Increases the production of vaginal secretions </li></ul>05/01/10 maninder ahuja
    26. 26. Local estrogens <ul><li>Localized ET is as effective as systemic ET for treating vaginal atrophy and is associated with fewer side effects. </li></ul><ul><li>Twice-weekly regimen often follows 1-2 weeks of daily administration </li></ul><ul><li>ER-alpha activity in vaginal cells decreases with age </li></ul><ul><li>There fore Vaginal estrogen therapy may require long-term treatment with increasing dosage of the hormone. </li></ul>05/01/10 maninder ahuja
    27. 27. Urinary symptoms <ul><li>Local vaginal estrogen therapy affects ERs in urethral mucosa and smooth muscle. </li></ul><ul><li>Although some studies have demonstrated a worsening of incontinence with oral therapies, </li></ul><ul><li>vaginal estrogen has reduced the frequency of urinary tract infections in menopausal women. </li></ul><ul><li>Perrotta C, Aznar M, Mejia R, Albert X, Ng CW: Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst. Rev. 2(2),CD005131 (2008) . </li></ul>05/01/10 maninder ahuja
    28. 28. Low dose vaginal estrogens are effective <ul><li>Usual dose of estradiol vaginal cream is 100 –400 mcg/day </li></ul><ul><li>Lower doses of 10 mcg/day, relieved more than 80% of symptoms, </li></ul><ul><li>Santen RJ, Pinkerton JV, Conaway M et al. : Treatment of urogenital atrophy with low-dose estradiol: preliminary results. Menopause 9(3),179–187 (2002). • Small pilot study on the positive effect of lower dose vaginal estrogen </li></ul>05/01/10 maninder ahuja
    29. 29. 05/01/10 maninder ahuja Even when giving sytemic HRT 27% Pts. have atrophic vaginitis so local treatment is preferred.
    30. 30. Vaginal Estrogen Therapy for Postmenopausal Use in the United States Modified from NAMS. Menopause Practice: A Clinician's local prepaGuide, 3rd edition. Cleveland, OH: The North American Menopause Society; 2007. 05/01/10 maninder ahuja Composition Product Name Dosing Vaginal Creams 17-beta-estradiol Estrace ® vaginal cream (Warner Chilcott, Rockaway, New Jersey) Initial: 2-4 g/day for 1-2 weeks Maintenance: 1 g/day (0.1-mg active ingredient/g) Conjugated estrogens (formerly conjugated equine estrogens) Premarin ® vaginal cream (Wyeth Pharmaceuticals Inc., Philadelphia, Pennsylvania) 0.5-2 g/day (0.625-mg active ingredient/g) Vaginal Rings 17-beta-estradiol ESTRING ® (Pfizer Inc., New York, NY) Device containing 2 mg releases 7.5 µg/day for 90 days Estradiol acetate Femring ® (Warner Chilcott, Rockaway, New Jersey) Device containing 12.4 mg or 24.8 mg estradiol acetate releases 0.05 mg/day or 0.10 mg/day for 90 days (systemic levels) Vaginal Tablet Estradiol hemihydrate VAGIFEM ® (Novo Nordisk Inc., Princeton, New Jersey) Initial: 1 tablet/day for 2 weeks Maintenance: 1 tablet twice/wk (tablet containing 25.8 µg estradiol hemihydrate equivalent to 25 µg of estradiol)
    31. 31. Low dose vaginal estrogen and endometrial cancer <ul><li>In the Cochrane review, no cases of endometrial cancer were reported. </li></ul><ul><li>Endometrial stimulation was found with 2% simple hyperplasia with vaginal ring compared with CEE and 4% hyperplasia (one simple and one complex) in the CEE compared with estradiol tablets. </li></ul><ul><li>Randomized studies with 25 µg 17ß-estradiol vaginal tablets found no increase in endometrial thickness. No Endometrial proliferation was noted after 1 year of use with the 2 mg vaginal ring . </li></ul><ul><li>Suckling J, Lethaby A, Kennedy R: Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst. Rev. 4(4),CD001500 (2006). </li></ul>05/01/10 maninder ahuja
    32. 32. Continued <ul><li>Dugal et al. compared estradiol vaginal tablets (25 mg 17ß-estradiol) or estriol vagitories (0.5 mg estriol) daily for 2 weeks, then twice weekly for a total duration of 24 weeks. </li></ul><ul><li>Endometrial thickness increased (1.1 and 0.5 mm with estradiol tablets and estriol cream, respectively) in both treatment groups during the first 2 weeks, but returned to baseline levels when the frequency was reduced to twice-weekly </li></ul>05/01/10 maninder ahuja
    33. 33. 05/01/10 maninder ahuja
    34. 34. Effect on breast? <ul><li>Reports conflicting regarding breast safety. </li></ul><ul><li>Rosenberg et al. found no associations between nonexclusive or exclusive use of local low-potency estrogen therapy and either ductal or lobular breast cancer </li></ul><ul><li>Kendall et al. found that the vaginal estradiol tablet significantly raised systemic estradiol levels greater than 19 pmol/l over low baseline estradiol levels and suggested that this could affect the estradiol suppression achieved by aromatase inhibitors in women with breast cancer. </li></ul><ul><li>Rosenberg LU, Magnusson C, Lindstrom E et al. : Menopausal hormone therapy and other breast cancer risk factors in relation to the risk of different histological subtypes of breast cancer: a case–control study. Breast Cancer Res. 8(1),R11 (2006). </li></ul><ul><li>Kendall A, Dowsett M, Folkerd E, Smith I: Caution: vaginal estradiol appears to be contraindicated in postmenopausal women on adjuvant aromatase inhibitors. Ann. Oncol. 17(4),584–587 (2006). </li></ul>05/01/10 maninder ahuja
    35. 35. Carry home message <ul><li>Specifically enquire about atrophic vaginitis symptoms </li></ul><ul><li>Counsel regarding the fact that it is progressive </li></ul><ul><li>More often use topical estrogens </li></ul><ul><li>No progestrone needed with local estrogen preparations </li></ul><ul><li>Even urinary symptoms may improve </li></ul><ul><li>Sexuality problems if because of vaginitis would improve </li></ul><ul><li>Local Ph testing would diagnose early </li></ul>05/01/10 maninder ahuja
    36. 36. THIS IS NOT END , THIS IS THE BEGINNIG OF OUR EFFORTS FOR QUALITY CARE! 05/01/10 maninder ahuja

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