2. History
62 year old postmenopausal widow presented
with Intermittent bleeding p/v for 2 months
Her obstetric career was uneventful, she had 3
normal deliveries
Her husband died 10 years back due to an
accident
She had no history or family h/o Gynaecological
malignancies.
She had no history DM / HT
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3. On examination
She looked pale but hemodynamically stable.
Pulse 86/min regular, BP was 130/80
There was no edema or icterus
Her RS & CVA appeared normal.
P/A exam revealed no abnormality
Her breast & auxillae were normal.
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4. On pelvic examination…
Her external genetalia appeared atrophic.
Slight bleeding was noticed coming from vagina.
On P/V exam, I could pass my one finger with
difficulty. Vaginal walls were edematous,
inflamed, non-elastic, bled on touch. Cervix
was small flushed with vagina.
On bimanual exam uterus was small mobile, non
tender , no adenexal mass felt.
P/S exam was not possible.
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5. Investigations
Her Hb was 8.5 g %, BT CT was normal
Blood sugar were within normal limits.
Urine exam showed few pus cells.
With cytobrush vaginal scrapings were sent for
cytology.
Cytology report showed plenty RBCs, pus cells &
parabasal cells. No maligant cells were seen.
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6. Diagnosis:
• With these findings diagnosis of
severe atrophic vaginitis was done
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7. Treatment Given
Oral Tab Premarin (Conjugated estrogens 0.625 mg )
1 tds X 2 week
1 bid X 2 weeks
1 OD X 2 months
Antibiotics
Ofloxacin with ornidazole X 5 days
Haematinics:
Iron + Bplex + Calcium & vit D3 X 3 months
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8. Follow-up
After 2 weeks of Tab Premarin, she started
showing subjective improvements,
her bleeding stopped completely.
On completion on three months I could pass my
two fingers easily, vagina was looking more
healthy & moist. Her Hb was 12.5 g %
Gradually I stopped her Oral Premarin.
I advised her Vaginal Estradiol tablets 25
micrograms once weekly for 3 months. She
was advised to continue taking calcium + vit
D3 supplements
She was called for follow-up after 3 months.
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9. Discussion
Severe atrophic vaginitis
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10. Prevalence
• About 40% of postmenopausal women
have symptoms related to vaginal
atrophy, most of whom require
treatment.
• However, only about 25% of
symptomatic women seek medical
attention
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12. Vaginal Epithelium
Four layers of vaginal wall.
• Stratified squamous epithelium
• Basal Layer
• Smooth muscle layer
• Adventatia
Note that there is no muscularis mucosa.
The vagina wall has no glands.
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15. Types of Vaginal Epithelial Cells
Parabasal Cells
Intermediate Cells
Superficial Cells
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16. Pathophysiology
• In the hormone-deprived state of menopause, the
urogenital epithelial and subepithelial tissues undergo
atrophic change.
• The connective tissue components of the vaginal
mucosa, including collagen, elastin, and smooth
muscle, all degenerate.
• Vaginal length and diameter shrink, the vaginal
fornices disappear, and the rugal folds of the vagina
are lost.
• Blood flow to the vagina is reduced, causing
decreased transudation during sexual arousal and
increased tissue susceptibility to trauma
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17. Pathophysiology(cont.)
• Vulvar sensitivity to pressure and light touch declines.
• The vaginal mucosa becomes thinner and less
cellular, and glycogen production declines, decreasing
the colonization of lactobacilli and thus lactic acid
production.
• The usual acidity of the vagina, which serves as a
potent defense mechanism, is lost, leading to an
overgrowth of enteric organisms
• Smokers may be at higher risk.
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18. Pathophysiology(cont.)
Postmenopausal women need to be
asked about the symptoms of
urogenital aging.
Many women will not spontaneously
report urogenital symptoms unless
directly questioned, and will therefore
needlessly suffer in silence.
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19. Hormone receptor
• The female introitus, vagina, bladder, and
urethra are all derived from the primitive
urogenital sinus, so it is not surprising that
these structures possess hormonal sensitivity
and demonstrate hormone receptor activity.
• At the introitus, estrogen and progesterone
receptors have been identified and are
predominantly vaginal in location,whereas
the majority of androgen receptors are found
in the vulva.
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20. Estrogen Receptors
Two types
• ERα
• ERβ
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21. Estrogen Receptors - α
The ERα is found in
• Vagina, pelvic floor muscles, Lower urinary
tract, endometrium & ovarian stroma
• Also in breast cancer cells and hypothalamus
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22. Estrogen Receptor - β
The ERβ has been documented
kidneys, brain, bone, heart, lungs,
intestinal mucosa, endothelial cells.
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23. Binding affinities for alpha and beta ERs
• 17-beta- estradiol binds equally well to both
receptors.
• Estrone and raloxifene bind preferentially to
the alpha receptor.
• Estriol and genistein to the beta receptor.
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26. Vaginal Maturation Index
Vaginal scrapings are used to determine maturation index
The maturation index determines the ratio of
parabasal, intermediate, and superficial cells and gives us
rough idea about status of vaginal walls.
Premenopause: 0-40-60
Perimenopause: 30-40-30
Postmenopause: 75-25-0
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27. Diagnosis
• Pelvic examination
• Cytological examination
• Biopsy may be required.
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28. Differntal Diagnosis
•Atrophic vaginitis
•Malignancies
Mostly squamous cell carcinomas, rarely
adenocarcinomas, Clear cell carcinoma,
Malignant melanoma and sarcomas
•Vaginal adenosis (women exposed to DES in utero)
•Vaginal lichen planus
•Vaginal candidiasis
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29. Vaginal cancer
Vaginal cancer is rare and accounts for only about
2% to 3% of cancers of the female reproductive
system.
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30. Management of Vaginal Atrophy
North American
Menopause society
Guidelines
(NAMS)
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31. Management of Vaginal Atrophy
(NAMS Guidelines March 2007)
The primary goals of vaginal atrophy
management are to relieve symptoms
and reverse atrophic anatomic changes.
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32. Management of Vaginal Atrophy
(NAMS Guidelines March 2007)
First-line therapies for women with
vaginal atrophy include nonhormonal
vaginal lubricants and moisturizers.
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33. Management of Vaginal Atrophy
(NAMS Guidelines March 2007)
For symptomatic vaginal atrophy that
does not respond to nonhormonal vaginal
lubricants and moisturizers,
prescription therapy may be required.
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34. Management of Vaginal Atrophy
(NAMS Guidelines March 2007)
Randomized controlled trials in postmenopausal
Women have shown that low-dose, local,
prescription vaginal estrogen delivery is
effective and well tolerated for treating vaginal
atrophy while limiting systemic absorption.
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35. Management of Vaginal Atrophy
(NAMS Guidelines March 2007)
All low-dose vaginal estrogen products like
Estradiol vaginal cream, CE vaginal cream,
the estradiol vaginal ring, and the estradiol
hemihydrate vaginal tablet are equally effective.
The choice is dependent on clinical experience and
patient preference.
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36. Management of Vaginal Atrophy
(NAMS Guidelines March 2007)
Progestogen is generally not indicated when
low-dose estrogen is administered locally for
vaginal atrophy.
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37. Management of Vaginal Atrophy
(NAMS Guidelines March 2007)
If a woman is at high risk for endometrial cancer, is
using a greater dose of vaginal ET, or is having
symptoms (spotting, breakthrough bleeding), closer
surveillance may be required.
There are insufficient data to recommend annual
endometrial surveillance in asymptomatic women
using vaginal ET.
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38. Management of Vaginal Atrophy
(NAMS Guidelines March 2007)
Vaginal ET should be continued as long as
Distressful symptoms remain.
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39. Management of Vaginal Atrophy
(NAMS Guidelines March 2007)
For women treated for non-hormone-dependent
cancer, management of vaginal atrophy is similar to
that for women without a cancer history.
For women with a history of hormone-dependent
cancer, management recommendations are dependent
upon each woman`s preference in consultation with
her oncologist.
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40. Management of Vaginal Atrophy
(SOGC Guidelines Feb 2006)
Continued regular vaginal coitus provides protection
from urogenital atrophy, presumably by increasing the
blood flow to the pelvic organs.
Masturbation has also been shown to increase genital
blood flow in menopausal women and may help
maintain urogenital health.
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