Atrophic vaginitis: Difference between revisions
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====Genetics==== | ====Genetics==== | ||
There are no genetic factors associated with atrophic vaginitis. | |||
====Gross Pathology==== | ====Gross Pathology==== | ||
Gross pathology findings in atrophic vaginitis include:<ref name="pmid24987271">{{cite journal |vauthors=Wysocki S, Kingsberg S, Krychman M |title=Management of Vaginal Atrophy: Implications from the REVIVE Survey |journal=Clin Med Insights Reprod Health |volume=8 |issue= |pages=23–30 |year=2014 |pmid=24987271 |pmc=4071759 |doi=10.4137/CMRH.S14498 |url=}}</ref> | |||
*Vaginal dryness | |||
*Loss of vaginal rugae | |||
*Changes in vaginal mucosa: pallor and friability or redness and petechiae of the mucosa | |||
====Microscopic Pathology==== | ====Microscopic Pathology==== | ||
====Associated Conditions==== | ====Associated Conditions==== | ||
==Causes== | ==Causes== | ||
Atrophic vaginitis is caused by any condition that may lead to decreased circulating estrogen levels. A hypoestrogenic state may be due to ovarian failure or other causes:<ref name="pmid27472999">{{cite journal |vauthors=Gandhi J, Chen A, Dagur G, Suh Y, Smith N, Cali B, Khan SA |title=Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management |journal=Am. J. Obstet. Gynecol. |volume= |issue= |pages= |year=2016 |pmid=27472999 |doi=10.1016/j.ajog.2016.07.045 |url=}}</ref> | |||
*Ovarian failure: this category includes [[menopause]], [[premature ovarian failure]], bilateral [[oophorectomy]], [[chemotherapy]] and [[radiation]] | |||
*Other causes: elevated [[prolactin]] levels, due to lactation or [[pituitary adenoma]], or medications that have an anti-estrogenic effect | |||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
| Line 74: | Line 84: | ||
==Natural History, Complications and Prognosis== | ==Natural History, Complications and Prognosis== | ||
===Natural History=== | |||
===Complications=== | |||
Complications of atrophic vaginitis include:<ref name="pmid27472999">{{cite journal |vauthors=Gandhi J, Chen A, Dagur G, Suh Y, Smith N, Cali B, Khan SA |title=Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management |journal=Am. J. Obstet. Gynecol. |volume= |issue= |pages= |year=2016 |pmid=27472999 |doi=10.1016/j.ajog.2016.07.045 |url=}}</ref><ref name="pmid16414323">{{cite journal |vauthors=Woods NF, Mitchell ES |title=Symptoms during the perimenopause: prevalence, severity, trajectory, and significance in women's lives |journal=Am. J. Med. |volume=118 Suppl 12B |issue= |pages=14–24 |year=2005 |pmid=16414323 |doi=10.1016/j.amjmed.2005.09.031 |url=}}</ref> | |||
*Stress urinary [[incontinence]] | |||
*Urge [[incontinence]] | |||
*[[Pelvic organ prolapse]] | |||
*Recurrent [[urinary tract infections]] | |||
*Sexual dysfunction | |||
===Prognosis=== | |||
==Diagnosis== | ==Diagnosis== | ||
===History and Symptoms=== | ===History and Symptoms=== | ||
Symptoms of atrophic vaginitis can be divided into three categories:<ref name=" | Symptoms of atrophic vaginitis can be divided into three categories:<ref name="pmid27472999">{{cite journal |vauthors=Gandhi J, Chen A, Dagur G, Suh Y, Smith N, Cali B, Khan SA |title=Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management |journal=Am. J. Obstet. Gynecol. |volume= |issue= |pages= |year=2016 |pmid=27472999 |doi=10.1016/j.ajog.2016.07.045 |url=}}</ref><ref name="pmid20042564">{{cite journal |vauthors=Mac Bride MB, Rhodes DJ, Shuster LT |title=Vulvovaginal atrophy |journal=Mayo Clin. Proc. |volume=85 |issue=1 |pages=87–94 |year=2010 |pmid=20042564 |pmc=2800285 |doi=10.4065/mcp.2009.0413 |url=}}</ref><ref name="pmid9332260">{{cite journal |vauthors=Pandit L, Ouslander JG |title=Postmenopausal vaginal atrophy and atrophic vaginitis |journal=Am. J. Med. Sci. |volume=314 |issue=4 |pages=228–31 |year=1997 |pmid=9332260 |doi= |url=}}</ref> | ||
*External genital symptoms: | *External genital symptoms: | ||
**Vaginal dryness | **Vaginal dryness | ||
| Line 96: | Line 117: | ||
**Urinary urgency | **Urinary urgency | ||
**[[Nocturia]] | **[[Nocturia]] | ||
** | **Urinary [[incontinence]] | ||
**Recurrent urinary tract infections ([[UTI]]) | **Recurrent urinary tract infections ([[UTI]]) | ||
===Physical Examination=== | ===Physical Examination=== | ||
Physical examination in women with atrophic vaginitis includes a general inspection of the external genitalia, as well as a speculum examination of the internal genitalia.<ref name="pmid9332260">{{cite journal |vauthors=Pandit L, Ouslander JG |title=Postmenopausal vaginal atrophy and atrophic vaginitis |journal=Am. J. Med. Sci. |volume=314 |issue=4 |pages=228–31 |year=1997 |pmid=9332260 |doi= |url=}}</ref><ref name="pmid10839558">{{cite journal |vauthors=Bachmann GA, Nevadunsky NS |title=Diagnosis and treatment of atrophic vaginitis |journal=Am Fam Physician |volume=61 |issue=10 |pages=3090–6 |year=2000 |pmid=10839558 |doi= |url=}}</ref> | |||
*Physical examination in women with atrophic vaginitis begins with inspection of the external genitalia. Findings include decreased elasticity of the skin, sparsity of pubic hair, dryness of the labia and/or fusion of the [[labia minora]]. | |||
*Gynecologic examination is carried using a small speculum to avoid damage to the atrophic vaginal or vulvar tissue. Vaginal epithelium may be atrophic and appear pale, smooth and shiny, or it may be inflamed, with patchy erythema, petechiae and increased friability. | |||
*Other findings may include: [[pelvic organ prolapse]], such as [[cystocele]] and/or [[rectocele]], urethral polyps or eversion of the urethral mucosa. | |||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
===CT=== | ===CT=== | ||
===MRI=== | ===MRI=== | ||
===Ultrasound=== | ===Ultrasound=== | ||
=== | An ultrasound of the uterus may demonstrate thinning of the endometrium lining to 4-5mm.<ref name="pmid10839558">{{cite journal |vauthors=Bachmann GA, Nevadunsky NS |title=Diagnosis and treatment of atrophic vaginitis |journal=Am Fam Physician |volume=61 |issue=10 |pages=3090–6 |year=2000 |pmid=10839558 |doi= |url=}}</ref> | ||
===Other Diagnostic Studies=== | ===Other Diagnostic Studies=== | ||
Revision as of 22:18, 24 October 2016
For patient information, click here
| Atrophic vaginitis | |
| ICD-10 | N95.2 |
|---|---|
| ICD-9 | 627.3 |
| DiseasesDB | 32516 |
| MedlinePlus | 000892 |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]
Synonyms and keywords: Atrophic vulvovaginitis; vaginal atrophy; urogenital atrophy; genitourinary syndrome of menopause
Overview
Historical Perspective
Classification
Pathophysiology
Pathogenesis
The pathogenesis of atrophic vaginitis is related to decreased estrogen levels. Estrogen is a vasoactive hormone, which increases blood flow and maintain vaginal lubrication through fluid transudation from blood vessels.[1] The following are the manifestations of decreased estrogen levels:[1][2][3]
- A hypoestrogenic state, such as that seen in menopause, causes the vaginal epithelium to lose its rugae, as well as become thin and pale or erythematous with fine petechial hemorrhages.
- Decreased glycogen content within the epithelium due to decreased thickness leads to less glycogen content available for the lactobacilli to utilize and turn it into lactic acid. As a result, the vaginal pH rises with a resultant overgrowth of other bacteria, such as group B streptococci, Staphylococci and diptheroids. As a result, vaginal infections, UTI and inflammation become more common in the setting of atrophic vaginitis.
Genetics
There are no genetic factors associated with atrophic vaginitis.
Gross Pathology
Gross pathology findings in atrophic vaginitis include:[4]
- Vaginal dryness
- Loss of vaginal rugae
- Changes in vaginal mucosa: pallor and friability or redness and petechiae of the mucosa
Microscopic Pathology
Associated Conditions
Causes
Atrophic vaginitis is caused by any condition that may lead to decreased circulating estrogen levels. A hypoestrogenic state may be due to ovarian failure or other causes:[1]
- Ovarian failure: this category includes menopause, premature ovarian failure, bilateral oophorectomy, chemotherapy and radiation
- Other causes: elevated prolactin levels, due to lactation or pituitary adenoma, or medications that have an anti-estrogenic effect
Epidemiology and Demographics
- Atrophic vaginitis is often an underdiagnosed condition, because many women are embarrassed to discuss their symptoms. Some others think of the symptoms associated with atrophic vaginitis as a process of natural aging.[1]
- Based on self-reported symptoms of vaginal dryness, the prevalence of atrophic vaginitis ranged from 4% to 47%, depending on the stage of menopause (early or late menopause).[2]
Risk Factors
The risk factors associated with vaginal atrophy are related to decreased estrogen levels, which can be due to menopause (most common cause) or other causes that may lead to hypoestrogenism or vaginal atrophy. These include:[1][5]
- Menopause (most common cause)
- Bilateral oophorectomy
- Premature ovarian failure
- Decreased ovarian function, due to chemotherapy or radiation
- Medications with an anti-estrogenic side effect:
- Tamoxifen
- Danazol
- Medroxyprogesterone acetate
- GnRH agonsists: leuprolide, nafarelin, goserelin
- GnRH antagonists: ganirelix
- Elevated prolactin levels during lactation
- Sexual abstinence
- Vaginal nulliparity
- Smoking
- Alcohol abuse
- Lack of exercise
Screening
There are no screening recommendations for atrophic vaginitis.[6]
Differentiating atrophic vaginitis from other diseases
Atrophic vaginitis must be differentiated from other disease processes that may present with similar symptoms. These can be divided into 4 categories:[2] [1]
- Vaginal infections: Candida vulvovaginitis, bacterial vaginosis and trichomoniasis
- Vulvovaginal dermatoses: lichen sclerosus, lichen planus and lichen simplex chronicus
- Cancer and precancerous lesions: vulvar intraepithelial neoplasia, vulvar cancer and extramammary Paget disease
- Others: foreign body, sexual trauma and contact irritants
Natural History, Complications and Prognosis
Natural History
Complications
Complications of atrophic vaginitis include:[1][7]
- Stress urinary incontinence
- Urge incontinence
- Pelvic organ prolapse
- Recurrent urinary tract infections
- Sexual dysfunction
Prognosis
Diagnosis
History and Symptoms
Symptoms of atrophic vaginitis can be divided into three categories:[1][2][3]
- External genital symptoms:
- Vaginal dryness
- Vaginal irritation
- Vaginal itching
- Vaginal discharge
- Sexual symptoms:
- Painful sexual intercourse (dyspareunia)
- Postcoital bleeding
- Loss of bleeding
- Loss of arousal
- Pelvic pain
- Urological symptoms:
- Burning on urination (dysuria)
- Urinary frequency
- Urinary urgency
- Nocturia
- Urinary incontinence
- Recurrent urinary tract infections (UTI)
Physical Examination
Physical examination in women with atrophic vaginitis includes a general inspection of the external genitalia, as well as a speculum examination of the internal genitalia.[3][5]
- Physical examination in women with atrophic vaginitis begins with inspection of the external genitalia. Findings include decreased elasticity of the skin, sparsity of pubic hair, dryness of the labia and/or fusion of the labia minora.
- Gynecologic examination is carried using a small speculum to avoid damage to the atrophic vaginal or vulvar tissue. Vaginal epithelium may be atrophic and appear pale, smooth and shiny, or it may be inflamed, with patchy erythema, petechiae and increased friability.
- Other findings may include: pelvic organ prolapse, such as cystocele and/or rectocele, urethral polyps or eversion of the urethral mucosa.
Laboratory Findings
CT
MRI
Ultrasound
An ultrasound of the uterus may demonstrate thinning of the endometrium lining to 4-5mm.[5]
Other Diagnostic Studies
Treatment
Medical Therapy
The mainstay of treatment of atrophic vaginitis is medical therapy. It can be categorized into two groups:[2][8]
- Nonhormonal therapy: this includes vaginal moisturizers and lubricants
- Hormonal therapy: this includes vaginally administered local estrogens, which can be in the form of cream, ring or tablet
Primary Prevention
Secondary Prevention
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Gandhi J, Chen A, Dagur G, Suh Y, Smith N, Cali B, Khan SA (2016). "Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management". Am. J. Obstet. Gynecol. doi:10.1016/j.ajog.2016.07.045. PMID 27472999.
- ↑ 2.0 2.1 2.2 2.3 2.4 Mac Bride MB, Rhodes DJ, Shuster LT (2010). "Vulvovaginal atrophy". Mayo Clin. Proc. 85 (1): 87–94. doi:10.4065/mcp.2009.0413. PMC 2800285. PMID 20042564.
- ↑ 3.0 3.1 3.2 Pandit L, Ouslander JG (1997). "Postmenopausal vaginal atrophy and atrophic vaginitis". Am. J. Med. Sci. 314 (4): 228–31. PMID 9332260.
- ↑ Wysocki S, Kingsberg S, Krychman M (2014). "Management of Vaginal Atrophy: Implications from the REVIVE Survey". Clin Med Insights Reprod Health. 8: 23–30. doi:10.4137/CMRH.S14498. PMC 4071759. PMID 24987271.
- ↑ 5.0 5.1 5.2 Bachmann GA, Nevadunsky NS (2000). "Diagnosis and treatment of atrophic vaginitis". Am Fam Physician. 61 (10): 3090–6. PMID 10839558.
- ↑ U.S. Preventive Services Task Force https://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=atrophic+vaginitis. Accessed on Oct. 24, 2016
- ↑ Woods NF, Mitchell ES (2005). "Symptoms during the perimenopause: prevalence, severity, trajectory, and significance in women's lives". Am. J. Med. 118 Suppl 12B: 14–24. doi:10.1016/j.amjmed.2005.09.031. PMID 16414323.
- ↑ Holmgren PA, Lindskog M, von Schoultz B (1989). "Vaginal rings for continuous low-dose release of oestradiol in the treatment of urogenital atrophy". Maturitas. 11 (1): 55–63. PMID 2498619.