Vaginal atrophy is a non–inflammatory disease characterized by thinning of the vaginal mucosa, its dryness and the development of dyspareunia. There is also a change in the acid-base state. The disease is manifested by a feeling of tightening, burning. The main cause of vaginal atrophy is a lack of estrogens, which are necessary for storing glycogen and maintaining the composition of normal microflora. Diagnosis is carried out during a gynecological examination, colposcopy, cytological examination and pH-metry are used. Treatment is aimed at replenishing estrogen deficiency.
ICD 10
N 95.2 N 95.3
General information
Vaginal atrophy to the early symptoms of approaching menopause. It is detected in 21% of perimenopausal women, when menstruation stops, burning and itching appear in 73% of patients. The most pronounced signs bother 4-6 years after artificial or natural menopause. At the age of 70 and older, vaginal atrophy is diagnosed in almost all women, may be accompanied by other urogenital disorders associated with a lack of female sex hormones.
Causes
In women, the condition of the vaginal mucosa depends on the functioning of the ovaries and the level of estrogen. They stimulate the storage of glycogen, which, when the epithelium is exfoliated, becomes a nutrient substrate for lacto- and bifidobacteria. Most often, vaginal atrophy is observed in late reproductive age, but it can develop in other conditions. The main reasons are:
- Natural menopause. From the age of 45, the function of the ovaries decreases, despite the stimulating effect of FSH, the concentration of estradiol in the blood decreases. Similar processes occur with the premature onset of menopause. With age, urogenital disorders become more pronounced, urinary incontinence joins.
- Artificial menopause. The condition develops in women who have undergone resection or total removal of the ovaries for medical reasons. Organ function may decrease after a course of radiation therapy in cancer patients. Estrogenic insufficiency is a direct consequence of treatment with antigonadotropins, gonadotropin-releasing hormone agonists.
- Chronic infectious colpitis. Long-term infectious inflammation, which is difficult to treat, or the absence of drug therapy for infectious pathology can lead to the development of atrophic phenomena on the mucous membrane. The composition of the normal microflora is disturbed, the protective properties of the epithelium disappear, the pH shifts to the alkaline side, which worsens well-being.
- Taking oral contraceptives. The composition of microdosed COCs includes ethinyl estradiol, which maintains the concentration of its own estrogens at the minimum permissible level. For some women, this amount is not enough, so atrophic processes are formed.
Pathogenesis
Changes in the urogenital tract relate to the early manifestations of menopause. They can appear at the first signs of a lack of estrogen, which are already noted at the age of 45. In women with ovarian depletion syndrome, estrogenic insufficiency is observed earlier. The lack of sex hormones leads to a decrease in the protective properties of vaginal secretions formed with the participation of lactobacilli and bifidobacteria.
With a decrease in the concentration of sex hormones, the epithelium loses its ability to store glycogen, the number of cell layers decreases. Bacteria do not have a substrate for reproduction, they die, and the pH rises due to the lack of lactic acid. The mucosa becomes thinner, becomes dry and vulnerable. The absence of protective factors contributes to the reproduction of opportunistic microflora or the development of bacterial vaginosis.
There are changes in blood flow in the vessels of the vagina. Tissues suffer from hypoxia, which increases the release of endothelial growth factor, which stimulates the formation of microcapillaries in the epithelial membrane. The epithelium is easily damaged, bleeds during manipulation. A long-term hypoxia condition can cause ulceration.
Classification
A special classification of vaginal atrophy has not been developed. The mechanisms that trigger the thinning of the epithelium and the appearance of characteristic symptoms, as well as treatment methods are similar in all cases of pathology, regardless of its cause. The International Classification of Diseases 10 revision identifies two variants of the disease:
- Postmenopausal atrophic vaginitis.
- Conditions associated with artificial menopause.
Symptoms
Symptoms of the disease occur gradually. At first, the feeling of discomfort in the labia region, the vestibule of the vagina begins to bother. Later it turns into a feeling of dryness and tightness of the skin. Sometimes pronounced atrophic processes on the labia minora lead to burning irritating pain. At the same time, sclerotic changes appear on the vulvar ring.
Dryness in the vagina with vaginal atrophy is felt as tightness of the skin, becomes noticeable during sexual intercourse. Even in a state of arousal, lubrication is not enough or it is completely absent, so sex is accompanied by pain. Easily injured, thinned mucosa in patients with vaginal atrophy leads to bleeding after sex. The amount of discharge is small, the bleeding stops on its own.
Pain in intimate relationships is also associated with sclerosis of the vulvar ring, as well as gradual constriction of the vagina, which loses its folding, becomes less stretchable. Sensitivity may vary. With persistent itching, a false feeling appears, resembling sexual arousal, during active frictions it fades and is replaced by pain.
The attachment of the infectious process is accompanied by characteristic secretions. Bacterial vaginosis leads to the appearance of the smell of rotten fish, which increases during sex or the use of soap. The discharge is abundant, white with a grayish tinge. With nonspecific inflammation, itching increases, dysuric disorders may be associated in the form of increased urge, discomfort when urinating. The discharge becomes yellowish.
Complications
Complications of vaginal atrophy develop when symptoms are ignored and untimely treatment. Far-reaching processes of atrophy lead to the appearance of vulvar kraurosis, which is characterized by unbearable itching, resistant to hormonal agents. Complications of atrophic processes may be associated with the addition of infection. If it spreads in an ascending way, there is a possibility of developing cervicitis, endometritis, adnexitis.
The lack of estrogens affects the entire urogenital tract. After the appearance of dryness and itching, atrophic processes spread to muscle and connective tissues. Women develop vaginal prolapse, which leads to urinary incontinence, its leakage during laughter, coughing. The urge to urinate, and sometimes to defecate, becomes imperative.
Diagnostics
Women need to be examined annually by an obstetrician-gynecologist to notice pathological changes at an early stage. If the results of the diagnosis reveal signs of severe dysplasia, an oncologist’s consultation is appointed. The examination is aimed at assessing the degree of atrophic changes in non-inflammatory colpitis. Used:
- Gynecological examination. When viewed in mirrors, the vaginal mucosa looks thinned, permeated with a large number of capillaries, bleeds easily when touched by mirrors. In women who are sexually active, petechial hemorrhages can be noticed.
- A smear from the vagina. The change in the composition of the vaginal microflora is determined. The number of Dederlein sticks decreases, the number of cocci increases, and key cells appear in bacterial vaginosis. Sometimes the hyphae of fungi or their cells are noticeable.
- Determination of vaginal pH. The study is carried out with vaginal secretions using special test strips. During premenopause, it can fluctuate at the level of 3.8-4.5, after 7-10 years from the moment of termination of menstruation, the pH increases to 5.5-6 and continues to rise.
- Cytological examination. The vaginal epithelium is atrophic, with a reduced amount of glycogen. Together with the pH-metry data, this allows you to set the index of vaginal health. On average, at the beginning of menopause, it is equal to 4-5 points, later it decreases to 1-2.
- Colposcopy. With extended colposcopy, branching vessels are visible on the pale pink surface of the mucous membrane, which bleed easily. When treated with Lugol’s solution, the epithelium is stained unevenly.
Treatment
In the treatment of the disease, preference is given to local remedies, the effect of which is limited to the urogenital tract. The woman is being treated at home, but periodically visits a gynecologist in a women’s consultation. Hospitalization in the department of gynecology is not required. Conservative therapy is carried out with the following drugs:
- Estriol. For the treatment of vaginal atrophy, it is prescribed in the form of cream or candles intravaginally. The course is selected individually, first the body is saturated with the hormone, then a smaller maintenance dosage is used. According to indications, it is used in tablets for oral administration.
- Estradiol valerate and levonorgestrel. It is available in the form of pills of 21 pcs. in a package. It is indicated in cases where treatment is required not only for senile colpitis, but also for other symptoms of menopause. The duration of hormone replacement therapy is determined individually.
- Estradiol and prasterone. For the treatment of signs of vaginal atrophy, it is recommended in the form of an oil solution intended for intramuscular administration. It is a depot form, can be prescribed in combination with local treatment with cream with estriol.
- Tibolon. It is used after the onset of natural or surgical menopause. It acts systematically, helps to eliminate the manifestations of atrophic vaginitis, as well as other signs of menopause, reduces the risk of osteoporosis.
- Antibiotics and antiseptics. For the treatment of bacterial vaginosis, candles or metronidazole tablets are used. When diagnosed with candidiasis colpitis, antifungal suppositories are prescribed. Treatment of nonspecific inflammation is carried out with candles with antiseptics, antibiotics or complex drugs.
Prognosis and prevention
With timely access to a doctor and the absence of contraindications to hormonal treatment, unpleasant symptoms can be reduced, the condition can be relieved with the help of local medications. Prevention of vaginal atrophy consists in a healthy lifestyle, prevention of infection with sexual infections, proper use of oral contraceptives. It is impossible to stop the onset of menopause, but with rational behavior during this period, a preventive visit to a gynecologist once a year, you can prepare for her arrival.
