Atrophic vaginitis is a condition that affects postmenopausal women, characterized by a pale, thin vaginal epithelium due to declining estrogen levels. Diagnosis involves examining symptoms, signs of vaginal dryness and atrophy, and ruling out other infections. Treatment begins with lubricants and moisturizers, while local estrogen therapies applied topically to the vagina are most effective at treating symptoms and reversing atrophy by improving blood flow and tissue health. Proper treatment typically provides relief, but may require long-term maintenance.

1. Atrophic Vaginitis www.freelivedoctor.com

2. Definition and Incidence Atrophic vaginitis, sometimes called vaginal atrophy, is a chronic progressive condition occurs mainly in postmenopausal women and is characterized by pale, thin, shining, shrunken and atrophic vaginal epithelium. In addition to vagina, the atrophic changes also affects the urinary tract because of their common embryologic origin. The condition develops slowly and it takes 5-10 years after menopause to manifest. Atrophic vaginitis affects 50-60% of postmenopausal women; of them only 25% seek medical advice. It may occur in women at childbearing period after delivery or with breastfeeding. www.freelivedoctor.com

3. Etiology 1-Menpopause: due to lack of estrogen. Dramatic decline in the circulating estrogen levels occurs at menopause from 120 pg/ml to 18 pg/ml 2-Pelvic irradiation or chemotherapy 3-Oophorectomy 4-Anti-estrogns: e.g. Tamoxifen, Danazol, Medroxyprogesterone, GnRh agonists 5-Immediately after delivery or breast feeding 6-Anorexic women & women who have recently lost a significant body weight 6-idiopathic www.freelivedoctor.com

4. Diagnosis A combined approach is mandatory to reach a correct diagnosis of atrophic vaginitis. This approach consists of; 1) proper history taking with special emphasis on any contact irritant such as local perfumes or deodorants or lubricants, 2) physical examination and 3) laboratory testings. Be careful to avoid the routine diagnosis of atrophic vaginitis in postmenopausal women with urogenital complaints. Exclude other causes of vaginal infection such as bacterial vaginosis, candidiasis or trichomoniasis. www.freelivedoctor.com

5. Diagnosis (Cont.) I- History : of -Frequency of urine, dysuria, nocturia, hematuria and incontinence. -Malodorous thick yellowish discharge. -Dyspareunia which may be followed by bleeding after intercourse. -Vaginal soreness and itching www.freelivedoctor.com

6. Diagnosis (Cont.) II- Physical examination : Vaginal examination should be performed using a small lubricated speculum to 1) avoid injury or bleeding from the atrophic vaginal tissues 2) minimize discomfort to the patient. Examination reveals: 1- Stenotic introitus: width is less then 2 fingers 2- Decreased vaginal depth. 3- Pale dry vagina with friable epithelium which lacks normal mucosal rugae www.freelivedoctor.com

7. Diagnosis (Cont.) -Diminished or absent elasticity of vagina. -Minimal vaginal lubrication due to decreased vaginal blood flow. -Petechiae may be present on the vaginal lining. -Vulvar tissue may appear diminished, obliterated, or even fused. -Clitoral shrinkage www.freelivedoctor.com

8. Diagnosis (Cont.) III- Laboratory testing: 1- PH: Vaginal pH in atrophic vaginitis is more than 5 measured with pH indicator strip inserted into the proximal one-third of the vagina 2-Low level of circulating estrogen <25 pg/mL 3-Microscopy (wet mount): to rule out vaginitis due to bacterial vaginosis , candidiasis, and trichomoniasis www.freelivedoctor.com

9. Diagnosis (Cont.) 4- Cytology : In a postmenopausal woman, due to lack of estrogen, a vaginal smear shows lack of maturation of vaginal cells (superficial cells < 30%) with predominance of intermediate, parabasal and metaplastic cells. These cells are characterized by the high nuclear cytoplasmic ratio, round nucleus, and basophilic cytoplasm. They are uniform in size and shape. Parabasal cells also may contain cytoplasmic vacuoles and are known as foam cells. In premenopausal & younger woman, vaginal cells are mature. i.e superficial. The superficial cells are large cells with either a small round pyknotic nucleus or lack a nucleus if they are cornified. Cytoplasm is abundant and keratinized. Cell margins are angular with folded edges. They are a rich source of glycogen for the lactobacilli. www.freelivedoctor.com

10. Complications Bacterial or fungal vaginal infections Cracks in the vaginal wall. Dyspareunia and bleeding after intercourse www.freelivedoctor.com

11. Treatment I- Prophylaxis: Post-menopausal women should be advised to continue regular sexual activity. Sexual activity improves blood circulation in the vagina, which helps maintain the tissue. Younger women who had their ovaries surgically removed or irradiated should start hormone replacement therapy. www.freelivedoctor.com

12. Treatment (Cont.) II- Curative: 1- Nonhormonal: First-line therapy for women with vaginal atrophy includes non-hormonal water soluble vaginal lubricants and moisturizers. Women should also be encouraged to continue sexual activity. www.freelivedoctor.com

13. Treatment (Cont.) 2- Hormonal : Bio-identical vaginal preparations are more effective than oral or transdermal preparations in releifing manifestations of atrophic vaginitis. Bio-identical vaginal estrogen require lower doses than systemic therapy; and it is the treatment of choice for such women Bio-identical vaginal estrogen therapy is available in many forms (creams, tablets, suppositories or rings). The best selection is the form that best suits an individual patient. www.freelivedoctor.com

14. Treatment (Cont.) Examples of bio-identical local vaginal estrogens:: 1- Estriol vaginal cream: One gram is applied to the vagina nightly for 7-10 nights then the dosage is reduced to 2–3 times per week for long-term maintenance. 2 Vagifem vaginal inserts: One insert is used in the vagina each night for 7–14 nights, and then reduced to one insert two nights per week for maintenance. www.freelivedoctor.com

15. Treatment (Cont.) 3- Estrace vaginal cream: 1 gram is applied to the vagina nightly for 7 -10 nights, then reduced to 1-3 times per week for long-term maintenance 4- Estring 90-day vaginal ring: 1 ring is inserted into the vagina and remains there for 90 days when it is removed & replaced with new ring. Premarin Vaginal Cream which is commonly prescribed by many gynecologists is not a bio-identical estrogen. Biodentical local estrogen are either equal or superior to, premarine. www.freelivedoctor.com

16. Treatment (Cont.) local bio-identical estrogens are always preferred to systemic estrogenic preparations. They improve atrophic vaginitis with minimal systemic absorption. Systemic estrogen administration in standard doses does not necessarily improves symptoms of atrophic vaginitis; however, higher doses improves manifestations of atrophic vaginitis in a large proportion of women (close to 85%). In addition, it has the advantage of decreasing postmenopausal bone loss and control of vasomotor dysfunction. www.freelivedoctor.com

17. Treatment (Cont.) Vaginal preparations improves symptoms and signs in 80% of women within 3 weeks of commencing therapy. Long term treatment with vaginal estrogenic may improve bone density and lower total cholesterol level, low density lipoprotein and apolipoprotein. Such preparations are unlikely to have adverse effects on long term use. Treatment should be continued till improvement occurs. Either continuous regimen or intermittent approach can be employed. www.freelivedoctor.com

18. Treatment (Cont.) Follow-up visits should include assessment of symptoms, vaginal morphology, and pH. Patients at high risk for endometrial cancer, & those using a higher E dose or having vaginal spotting or breakthrough bleeding may require closer surveillance. Women with hormone-dependent cancer are not ideal candidates for treatment with local E, but such women with severe symptoms not improved with conservative measures may be considered for E therapy www.freelivedoctor.com

19. Side effects of local estrogen therapy 1-Breast discomfort 2-Vaginal bleeding Both 1 and 2 are the commonest side effects 3-Endometrial proliferation 4-A slight increase in the risk of an estrogen-dependent neoplasm. www.freelivedoctor.com

20. 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. Prognosis The condition usually responds to proper treatment. In resistant cases, the uterus should be curetted to exclude endometrial carcinoma or associated senile endometritis. www.freelivedoctor.com