VULVOVAGINITIS, ESTROGEN DEFICIENT

VULVOVAGINITIS, ESTROGEN DEFICIENT - Michael P. Hopkins, MD, Med; Jamie Byler, MD; Eric L. Jenison, MD
BASICS
DESCRIPTION
• Decreased blood flow with thinning and atrophy of the female genital tissue
• Changes from estrogen deficiency occur throughout the body; the genital tissues are especially hormone responsive.
• Estrogen-deficient vulvovaginitis is frequently associated with urinary incontinence.
• System(s) Affected: Reproductive
EPIDEMIOLOGY
• Predominant age: Predominantly a problem of the postmenopausal female. The average age of menopause in the US is 52.5 years.
• Predominant sex: Female only
Prevalence
This disorder will affect all women to some degree unless estrogen replacement therapy (ERT) is provided.
RISK FACTORS
• Estrogen-deficient states accompanying metabolic disorders
• Vaginal infections with bacteria and fungi
Genetics
No known pattern
ETIOLOGY
Estrogen deficiency due to
• Menopause (surgical or natural)
• Ovariectomy
• Radiation of the pelvis
ASSOCIATED CONDITIONS
• Incontinence
• Pelvic organ prolapse
• Frequent urinary tract infections

DIAGNOSIS
SIGNS AND SYMPTOMS
• Vaginal dryness
• Decreased vaginal secretions
• Dyspareunia
• Vulva undergoes a thinning of the epidermis along with decreased integrity of the supporting structures; the thinning and atrophy often produce pruritus.
• Obese patients, especially those weighing >100 lb (45 kg) over an ideal body weight, have higher levels of circulating estrogen and thus may have fewer symptoms. (Androstenedione is converted to estrone in peripheral adipose tissue, and when there is an abundance of adipose, higher estrone levels are present.)
Physical Exam
Examination of the vagina and the vulva for maturation index
TESTS
Lab
• Cytology for maturation index will show a low maturation index, signifying a decreased turnover of the cells from the decreased estrogen effect.
• Check the follicle-stimulating hormone (FSH) level to confirm menopause. In the perimenopausal or menopausal female, FSH will be elevated and estradiol will be decreased.
• Estradiol level to evaluate circulating estrogen level
• Drugs that may alter lab results
- Estrogen therapy will alter the maturation index.
- Digoxin has estrogenlike properties.
- Tamoxifen (Nolvadex) may produce menopausal-type symptoms, but may also act on genital tissues as a weak estrogen agonist. Symptoms may vary.
- Drugs used to treat endometriosis or uterine bleeding, such as progestins, danazol, or gonadotropin-releasing hormone agonists, may produce a pseudomenopause, which is reversible.
Pathological Findings
Thinning of the cornified squamous layer of both the vulva and the vagina
DIFFERENTIAL DIAGNOSIS
• Malignancy
• Vulvar dystrophies
TREATMENT
STABILIZATION
Outpatient treatment
GENERAL MEASURES
• ERT will alleviate and reverse the symptoms and the thinning of the squamous epithelial layer. Replacement therapy leads to an increased blood supply to the genital tissues.
• OTC vaginal lubricants
• Symptomatic relief if needed, e.g., cool baths or compresses
Diet
No special diet
Activity
No restriction
MEDICATION (DRUGS)
First Line (1,2)[A]
• A wide variety of preparations are available.
• Progesterone should be used in women with an intact uterus when given estrogen to decrease risk of endometrial carcinoma.
- Estrogen, conjugated: 0.625 mg/d
- Estradiol: 1 mg/d
- Estradiol patch: 0.05 mg, changed twice weekly
- Estrogen vaginal preparations
 Cream
 Tablet
 Ring
• Contraindications
- Estrogen therapy is contraindicated in patients with a history of breast cancer with estrogen-positive tumor receptors.
- Undiagnosed uterine bleeding
- A history of uterine malignancy is a relative contraindication.
• Precautions: Refer to the manufacturer's literature.
• Significant possible interactions: Refer to the manufacturer's literature.
FOLLOW-UP
PROGNOSIS
The prognosis is excellent. The vast majority of symptoms will be relieved with ERT.
COMPLICATIONS (2)[A]
Those associated with estrogen replacement
• Postmenopausal bleeding
• Nausea
• Headache
• Libido changes
• Thrombophlebitis
• Thromboembolic events (coronary, stroke)
• Breast cancer
• Gallbladder disease
• Uterine cancer
PATIENT MONITORING
The patient should be instructed that symptoms should resolve within 30-60 days. If they do not, reevaluation and reexamination for other causes should be undertaken.
REFERENCES
1. Suckling J, Lethaby A, Kennedy R. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2003;4:CD001500.
2. Farquhar CM, et al. Cochrane HT Study Group. Long term hormone therapy for perimenopausal and postmenopausal women. Cochrane Database Syst Rev. 2005;3:CD004143.