Atrophic vaginitis: Difference between revisions

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'''For patient information, click [[Atrophic vaginitis (patient information)|here]]'''
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'''For patient information, click [[Atrophic vaginitis (patient information)|here]]''' <br>
'''To view the Vaginitis main page [[Vaginitis | Click here]]'''


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==Overview==
==Overview==
[[Atrophic vaginitis]] is defined as [[inflammation]] of the vaginal epithelium due to [[atrophy]], secondary to decreased levels of circulating [[estrogen]]. The features of this disease are estimated to be seen manifests 15% [[premenopausal]] and 50% [[menopausal]] women. Patients present with the symptoms of [[vaginal dryness]], [[itching]], [[irritation]], and [[dyspareunia]]. Diagnosis of atrophic vaginitis requires subjective assessment of the severity of symptoms to be correlated with the physical exam findings. The prominent physical examination findings include atrophic vaginal or vulvar tissue, pale, smooth and shiny vaginal epithelium with increased friability and inflammation with patchy [[erythema]]. The characteristic findings to confirm the diagnosis are- a left shift of the vaginal maturation index on a vaginal smear and a alkaline pH of the vagina. However, other secondary causes such as [[Lichen Sclerosus]] and [[Lichen planus|Lichen Planus]] must be ruled before the confirmation of the diagnosis. The therapeutic management is based on the severity of the symptoms-lubricants are the first line of therapy for mild symptoms, topical or oral [[estrogen]] therapy is effective for the management of patients unresponsive to lubricants and with moderate to severe symptoms. Majority of the patients have resolution of symptoms but as it is a chronic progressive condition it requires continuous treatment.
Atrophic vaginitis is defined as [[inflammation]] of the vaginal epithelium due to [[atrophy]] secondary to decreased levels of circulating [[estrogen]]. The features of this disease are estimated to be seen in 15% of [[premenopausal]] and 50% [[menopausal]] women. Patients present with the symptoms of [[vaginal dryness]], [[itching]], [[irritation]], and [[dyspareunia]]. Diagnosis of atrophic vaginitis requires subjective assessment of the severity of symptoms to be correlated with the physical examination findings. The prominent physical examination findings include atrophic vaginal or vulvar tissue, pale, smooth and shiny vaginal [[epithelium]] with increased [[friability]] and [[inflammation]] with patchy [[erythema]]. The characteristic findings to confirm the diagnosis are: a left shift of the vaginal maturation index on a vaginal smear and a alkaline [[pH]] of the [[vagina]]. However, other secondary causes such as [[lichen sclerosus]] and [[Lichen planus|lichen planus]] must be ruled before the confirmation of the diagnosis. The therapeutic management is based on the severity of the symptoms: [[lubricants]] are the first line of therapy for mild symptoms, in patients unresponsive to lubricants and with moderate to severe symptoms [[topical]] or oral [[estrogen]] therapy is effective for the management of patients . Majority of the patients have resolution of symptoms but due to the chronic nature of the condition it requires continuous treatment.


==Historical Perspective==
==Historical Perspective==
*In 1898, Charles B. Penrose described [[vaginitis]] in elderly women as senile Vaginitis. The areas of patchy [[inflammation]] were treated with 5% [[silver nitrate]] solution.<ref name="urlA Text-book of Diseases of Women - Charles Bingham Penrose - Google Books">{{cite web |url=https://books.google.com/books?hl=en&lr=&id=6CE1AQAAMAAJ&oi=fnd&pg=PA17&dq=ATROPHIC+VAGINITIS&ots=9zog_L9A_S&sig=360tq_c0mnTVC-CmCCgoyS0Djpg#v=onepage&q&f=false |title=A Text-book of Diseases of Women - Charles Bingham Penrose - Google Books |format= |work= |accessdate=}}</ref>
*In 1940, Jacob described the use of [[vaginal]] [[pH]] in determination of hypoestrogenic state.<ref name="Beilly1940">{{cite journal|last1=Beilly|first1=Jacob S.|title=DETERMINATION OF PH OF VAGINAL SECRETION AS AN INDEX OF OVARIAN ACTIVITY IN HYPOOVARIAN STATES|journal=Endocrinology|volume=26|issue=6|year=1940|pages=959–964|issn=0013-7227|doi=10.1210/endo-26-6-959}}</ref>
*In 1947, Racoff gave a description the efficacy and safety of a synthetic [[estrogen]], [[dienestrol]] for the treatment of menopausal syndrome and atrophic vaginitis is described.<ref name="RakoffPaschkis1947">{{cite journal|last1=Rakoff|first1=A. E.|last2=Paschkis|first2=K. E.|last3=Cantarow|first3=A.|title=A CLINICAL EVALUATION OF DIENESTROL, A SYNTHETIC ESTROGEN1|journal=The Journal of Clinical Endocrinology & Metabolism|volume=7|issue=10|year=1947|pages=688–700|issn=0021-972X|doi=10.1210/jcem-7-10-688}}</ref>
*In 1963, topical [[Dinesterol]] vaginal cream was used for the treatment of senile vaginitis.<ref name="FalkHassid1963">{{cite journal|last1=Falk|first1=Henry C.|last2=Hassid|first2=Roger|title=ATROPHIC OR SENILE VAGINITIS: TREATMENT WITH DIENESTROL CREAM|journal=Journal of the American Geriatrics Society|volume=11|issue=12|year=1963|pages=1152–1157|issn=00028614|doi=10.1111/j.1532-5415.1963.tb02686.x}}</ref>
*In 1967, the relationship between the vaginal maturation index and [[estrogen therapy]] was described.<ref name="urlLimited Relationship of Maturation Index to Estrogen Therapy... : Obstetrics & Gynecology">{{cite web |url=http://journals.lww.com/greenjournal/Citation/1967/30030/Limited_Relationship_of_Maturation_Index_to.14.aspx |title=Limited Relationship of Maturation Index to Estrogen Therapy... : Obstetrics & Gynecology |format= |work= |accessdate=}}</ref>
*In 2013, vulvovaginal atrophy is renamed as genitourinary syndrome of menopause.<ref name="pmid25179577">{{cite journal| author=Portman DJ, Gass ML, Vulvovaginal Atrophy Terminology Consensus Conference Panel| title=Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. | journal=Maturitas | year= 2014 | volume= 79 | issue= 3 | pages= 349-54 | pmid=25179577 | doi=10.1016/j.maturitas.2014.07.013 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25179577  }} </ref>


==Classification==
==Classification==
Atrophic vaginitis is classified based on the symptom severity into:<ref name="Domoney2014">{{cite journal|last1=Domoney|first1=Claudine|title=Treatment of vaginal atrophy|journal=Women's Health|volume=10|issue=2|year=2014|pages=191–200|issn=1745-5057|doi=10.2217/whe.14.9}}</ref>
Atrophic vaginitis is classified based on the symptom severity into:<ref name="Domoney2014">{{cite journal|last1=Domoney|first1=Claudine|title=Treatment of vaginal atrophy|journal=Women's Health|volume=10|issue=2|year=2014|pages=191–200|issn=1745-5057|doi=10.2217/whe.14.9}}</ref>
*'''Mild''': Patients present with symptoms related to sexual activity.
*'''Mild''': Patients present with symptoms related to [[sexual activity]].
*'''Moderate to severe''': Patients with persistent symptoms not related to sexual activity.
*'''Moderate to severe''': Patients with persistent symptoms not related to [[sexual activity]].


==Pathophysiology==
==Pathophysiology==
====Pathogenesis====
====Pathogenesis====
The pathogenesis of atrophic vaginitis is due to decreased [[estrogen]] levels. Estrogen is a [[vasoactive]] hormone, which increases blood flow and maintain [[vaginal lubrication]] through fluid transudation from blood vessels.<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> The following are the manifestations of decreased estrogen levels:<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>
The pathogenesis of atrophic vaginitis is due to decreased [[estrogen]] levels. [[Estrogen]] is a [[vasoactive]] hormone, which increases blood flow and maintains [[vaginal lubrication]] through fluid [[transudation]] from [[blood vessels]].<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> The following are the manifestations of decreased estrogen levels:<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>
*A hypoestrogenic state, such as that seen in menopause causes breakdown of [[collagen]] and elastic fibres in the vagina resulting in vaginal epithelium to lose its [[rugae]] to become thin and pale or [[erythematous]] with fine [[petechial hemorrhages]] and a narrow and shortened vagina.
*A [[hypoestrogenic]] state causes the breakdown of [[collagen]] and [[elastic fibres]] in the [[vagina]] resulting in vaginal [[epithelium]] to lose its [[rugae]] to 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]].  Vaginal pH rises with a resultant overgrowth of other bacteria, such as [[group B streptococci]], [[Staphylococci]] and diptheroids leading to recurrent vaginal infections and [[UTI]].
*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]].  Vaginal [[pH]] rises with a resultant overgrowth of other [[bacteria]], such as [[group B streptococci]], [[staphylococci]] and [[diptheroids]] leading to recurrent vaginal infections and [[UTI]].


====Genetics====
====Genetics====
There are no genetic factors associated with [[atrophic vaginitis.]]
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>
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
*Vaginal dryness
*Loss of vaginal rugae
*Loss of vaginal rugae
*Changes in vaginal mucosa: pallor and friability or redness and [[petechiae]] of the mucosa
*Changes in vaginal mucosa: pallor and friability or redness and [[petechiae]] of the [[mucosa]]


====Microscopic Pathology====
====Microscopic Pathology====
*Cytology of the vaginal cells show an increase in the parabasal cells and decreased superficial cells. In situations of low estrogen levels the vaginal epithelium ceases to produce superficial and intermediate squamous cells, leaving only the parabasal and basal cells lining the vaginal wall.
*[[Cytology]] of the vaginal cells show an increase in the parabasal cells and decreased superficial cells. In situations of low [[estrogen]] levels the vaginal epithelium ceases to produce superficial and intermediate squamous cells, leaving only the parabasal and basal cells lining the vaginal wall.<ref name="pmid10082300">{{cite journal| author=van der Laak JA, Schijf CP, Kerstens HM, Heijnen-Wijnen TH, de Wilde PC, Hanselaar GJ| title=Development and validation of a computerized cytomorphometric method to assess the maturation of vaginal epithelial cells. | journal=Cytometry | year= 1999 | volume= 35 | issue= 3 | pages= 196-202 | pmid=10082300 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10082300  }} </ref>


====Associated Conditions====
====Associated Conditions====
*Atrophic vaginitis is characterized with pale dry vaginal epithelium and increased pH. This predisposes the patients to recurrent vaginal infections with common pathogens such as Candida, Gardnella vaginalis and Trichomonas, therefore it is essential to rule out these infections.
*Atrophic vaginitis is characterized with pale dry vaginal [[epithelium]] and increased [[pH]]. This predisposes the patients to recurrent vaginal infections with common pathogens such as [[candida]], [[gardnerella vaginalis]] and [[trichomonas]], therefore it is essential to rule out these infections.
*Scarring and atrophy is also a feature of [[Lichen Sclerosus]] and [[Lichen Planus]] which can co-exist with atrophic vaginitis.<ref name="Lewis2015">{{cite journal|last1=Lewis|first1=F. M.|title=Vulval symptoms after the menopause - Not all atrophy!|journal=Post Reproductive Health|volume=21|issue=4|year=2015|pages=146–150|issn=2053-3691|doi=10.1177/2053369115608019}}</ref>
*[[Scarring]] and [[atrophy]] are features of [[lichen sclerosis]] and [[lichen planus]] which can co-exist with atrophic vaginitis.<ref name="Lewis2015">{{cite journal|last1=Lewis|first1=F. M.|title=Vulval symptoms after the menopause - Not all atrophy!|journal=Post Reproductive Health|volume=21|issue=4|year=2015|pages=146–150|issn=2053-3691|doi=10.1177/2053369115608019}}</ref>


==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>
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
{| class="wikitable"
{| class="wikitable"
!Ovarian Failure  
!Ovarian Failure  
!Other causes  
!Other causes  
|-
|-
|Menopause
|[[Menopause]]
|Elevated Prolactin Postpartum
|Elevated [[Prolactin]] during the [[Postpartum]] period
|-
|-
|Premature Ovarian Failure  
|[[Premature Ovarian Failure]]
Bilateral oophorectomy
Bilateral [[oophorectomy]]
|Pituitary Adenoma
|Pituitary [[Adenoma]]
|-
|-
|Chemotherapy and Radiation
|[[Chemotherapy]] and [[Radiation]]
|Medication with anti-estrogenic effect
|Medications with anti-estrogenic effect
|}
|}


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**Only 25% of patients with symptoms seek medical care.<ref name="pmid15151738">{{cite journal| author=Johnston SL, Farrell SA, Bouchard C, Farrell SA, Beckerson LA, Comeau M et al.| title=The detection and management of vaginal atrophy. | journal=J Obstet Gynaecol Can | year= 2004 | volume= 26 | issue= 5 | pages= 503-15 | pmid=15151738 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15151738  }} </ref>
**Only 25% of patients with symptoms seek medical care.<ref name="pmid15151738">{{cite journal| author=Johnston SL, Farrell SA, Bouchard C, Farrell SA, Beckerson LA, Comeau M et al.| title=The detection and management of vaginal atrophy. | journal=J Obstet Gynaecol Can | year= 2004 | volume= 26 | issue= 5 | pages= 503-15 | pmid=15151738 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15151738  }} </ref>
**Inadequate relief of symptoms with treatment.<ref name="pmid23679050">{{cite journal| author=Kingsberg SA, Wysocki S, Magnus L, Krychman ML| title=Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women's VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. | journal=J Sex Med | year= 2013 | volume= 10 | issue= 7 | pages= 1790-9 | pmid=23679050 | doi=10.1111/jsm.12190 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23679050  }} </ref>
**Inadequate relief of symptoms with treatment.<ref name="pmid23679050">{{cite journal| author=Kingsberg SA, Wysocki S, Magnus L, Krychman ML| title=Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women's VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. | journal=J Sex Med | year= 2013 | volume= 10 | issue= 7 | pages= 1790-9 | pmid=23679050 | doi=10.1111/jsm.12190 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23679050  }} </ref>
*The features of atrophic vaginitis are estimated to be seen in 15% of premenopausal women and 40-54% of post-menopausal women.<ref name="DiBonaventuraLuo2015">{{cite journal|last1=DiBonaventura|first1=Marco|last2=Luo|first2=Xuemei|last3=Moffatt|first3=Margaret|last4=Bushmakin|first4=Andrew G.|last5=Kumar|first5=Maya|last6=Bobula|first6=Joel|title=The Association Between Vulvovaginal Atrophy Symptoms and Quality of Life Among Postmenopausal Women in the United States and Western Europe|journal=Journal of Women'sHealth|volume=24|issue=9|year=2015|pages=713–722|issn=1540-9996|doi=10.1089/jwh.2014.5177}}</ref>
*The features of atrophic vaginitis are estimated to be seen in 15% of [[Premenopausal|premenopausa]]<nowiki/>l women and 40-54% of post-menopausal women.<ref name="DiBonaventuraLuo2015">{{cite journal|last1=DiBonaventura|first1=Marco|last2=Luo|first2=Xuemei|last3=Moffatt|first3=Margaret|last4=Bushmakin|first4=Andrew G.|last5=Kumar|first5=Maya|last6=Bobula|first6=Joel|title=The Association Between Vulvovaginal Atrophy Symptoms and Quality of Life Among Postmenopausal Women in the United States and Western Europe|journal=Journal of Women'sHealth|volume=24|issue=9|year=2015|pages=713–722|issn=1540-9996|doi=10.1089/jwh.2014.5177}}</ref>
*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).<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>
*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]]).<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>


==Risk Factors==
==Risk Factors==
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*Sexual abstinence
*Sexual abstinence
*Vaginal [[nulliparity]]
*Vaginal [[nulliparity]]
*Smoking
*[[Smoking]]
*Alcohol abuse
*[[Alcoholism|Alcohol abuse]]
*Lack of exercise
*Lack of exercise
==Screening==
==Screening==
There are no screening recommendations for atrophic vaginitis.<ref name="USPSTF"> U.S. Preventive Services Task Force https://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=atrophic+vaginitis. Accessed on Oct. 24, 2016</ref>
There are no screening recommendations for atrophic vaginitis.<ref name="USPSTF"> U.S. Preventive Services Task Force https://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=atrophic+vaginitis. Accessed on Oct. 24, 2016</ref>
==Differentiating atrophic vaginitis from other diseases==
==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:<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="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>
Atrophic vaginitis must be differentiated from other disease processes that may present with similar symptoms. These can be divided into 4 categories:<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="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>
*Vaginal infections: [[Candida]] [[vulvovaginitis]], [[bacterial vaginosis]] and [[trichomoniasis]]
*'''Vaginal infections''': [[Candida]] [[vulvovaginitis]], [[bacterial vaginosis]] and [[trichomoniasis]]
*[[Vulvovaginal]] dermatoses: [[lichen sclerosus]], [[lichen planus]] and [[lichen simplex chronicus]]
*[[Vulvovaginal|'''Vulvovaginal''']] '''dermatoses''': [[Lichen sclerosus]], [[lichen planus]] and [[lichen simplex chronicus]]
*Cancer and precancerous lesions: [[vulvar intraepithelial neoplasia]], [[vulvar cancer]] and [[extramammary Paget disease]]
*'''Cancer and precancerous lesions''': [[Vulvar intraepithelial neoplasia]], [[vulvar cancer]] and [[extramammary paget disease]]
*Others: foreign body, sexual trauma and contact irritants
*'''Others''': Foreign body, sexual trauma and contact irritants
 
The conditions which may need to be differentiated from the atrophic vagintis and presents as vulvar or vaginal [[pruritus]], [[dryness]], [[discharge]] and [[dyspareunia]] include the following: <ref name="pmid26125955">{{cite journal| author=Guerrero A, Venkatesan A| title=Inflammatory Vulvar Dermatoses. | journal=Clin Obstet Gynecol | year= 2015 | volume= 58 | issue= 3 | pages= 464-75 | pmid=26125955 | doi=10.1097/GRF.0000000000000125 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26125955  }} </ref><ref name=CDC-BV> Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines. Bacterial Vaginosis. http://www.cdc.gov/std/tg2015/bv.htm Accessed on October 13, 2016 </ref><ref name="pmid10839558">{{cite journal| author=Bachmann GA, Nevadunsky NS| title=Diagnosis and treatment of atrophic vaginitis. | journal=Am Fam Physician | year= 2000 | volume= 61 | issue= 10 | pages= 3090-6 | pmid=10839558 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10839558  }} </ref><ref name="pmid2448502">{{cite journal| author=Krieger JN, Tam MR, Stevens CE, Nielsen IO, Hale J, Kiviat NB et al.| title=Diagnosis of trichomoniasis. Comparison of conventional wet-mount examination with cytologic studies, cultures, and monoclonal antibody staining of direct specimens. | journal=JAMA | year= 1988 | volume= 259 | issue= 8 | pages= 1223-7 | pmid=2448502 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2448502  }} </ref><ref name="pmid97946645">{{cite journal| author=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK| title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. | journal=Obstet Gynecol | year= 1998 | volume= 92 | issue= 5 | pages= 757-65 | pmid=9794664 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9794664  }}</ref>
The following is a list of differential diagnosis for Atrophic Vaginits: <ref name="pmid26125955">{{cite journal| author=Guerrero A, Venkatesan A| title=Inflammatory Vulvar Dermatoses. | journal=Clin Obstet Gynecol | year= 2015 | volume= 58 | issue= 3 | pages= 464-75 | pmid=26125955 | doi=10.1097/GRF.0000000000000125 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26125955  }} </ref><ref name=CDC-BV> Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines. Bacterial Vaginosis. http://www.cdc.gov/std/tg2015/bv.htm Accessed on October 13, 2016 </ref><ref name="pmid10839558">{{cite journal| author=Bachmann GA, Nevadunsky NS| title=Diagnosis and treatment of atrophic vaginitis. | journal=Am Fam Physician | year= 2000 | volume= 61 | issue= 10 | pages= 3090-6 | pmid=10839558 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10839558  }} </ref><ref name="pmid2448502">{{cite journal| author=Krieger JN, Tam MR, Stevens CE, Nielsen IO, Hale J, Kiviat NB et al.| title=Diagnosis of trichomoniasis. Comparison of conventional wet-mount examination with cytologic studies, cultures, and monoclonal antibody staining of direct specimens. | journal=JAMA | year= 1988 | volume= 259 | issue= 8 | pages= 1223-7 | pmid=2448502 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2448502  }} </ref><ref name="pmid97946645">{{cite journal| author=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK| title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. | journal=Obstet Gynecol | year= 1998 | volume= 92 | issue= 5 | pages= 757-65 | pmid=9794664 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9794664  }}</ref>
 
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*Progressive symptoms   
*Progressive symptoms   
*Presents with yellow and malodorous vaginal discharge, vaginal dryness, postcoital bleeding, and [[dyspareunia]] with the signs of vaginal [[inflammation]] and elevated vaginal pH (>5)
*Presents with yellow and malodorous [[vaginal discharge]], vaginal dryness, [[postcoital bleeding]], and [[dyspareunia]] with the signs of vaginal [[inflammation]] and elevated vaginal [[pH]] (>5)
*Diagnosis is critical and laboratory tests help to confirm hypoestrogenic state  
*Diagnosis is critical and laboratory tests help to confirm [[hypoestrogenic state]]
|-
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| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Trichomoniasis]]'''
| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Trichomoniasis]]'''
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*Presents with purulent, malodorous, thin discharge associated with burning, [[pruritus]], and [[dysuria]], with the signs of vaginal [[inflammation]] and elevated vaginal [[pH]] (>4.5)
*Presents with purulent, malodorous, thin discharge associated with burning, [[pruritus]], and [[dysuria]], with the signs of vaginal [[inflammation]] and elevated vaginal [[pH]] (>4.5)
*Motile trichomonads on wet mount are demonstrated  
*Motile trichomonads on [[wet mount]] are demonstrated  
*Positive culture (Gold standard)
*Positive [[culture]](Gold standard)
*Positive nucleic acid amplification test (NAAT)  
*Positive [[nucleic acid amplification test]] ([[NAAT]])  
|-
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Bacterial Vaginosis]]'''
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Bacterial Vaginosis]]'''
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*Presents with [[dysuria]], vaginal discharge
*Presents with [[dysuria]], [[vaginal discharge]]
*Fishy odor (positive whiff test)
*Fishy odor on [[whiff test]]
*Normal vaginal PH (<4.5)
*Normal vaginal [[PH]] (<4.5)
*On speculum examination signs of vaginal inflammation are demonstrated
*On speculum examination signs of vaginal [[inflammation]] are demonstrated
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| style="padding: 5px 5px; background: #DCDCDC;" |  '''[[Candida Vulvovaginitis]]'''
| style="padding: 5px 5px; background: #DCDCDC;" |  '''[[Candida Vulvovaginitis]]'''
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*Presents with vulvar pruritus and cottage cheese-like vaginal discharge with no or minimal odor with normal vaginal pH (4-4.5)
*Presents with vulvar [[pruritus]] and cottage cheese-like [[vaginal discharge]] with no or minimal odor with normal vaginal [[pH]] (4-4.5)
*presence of [[Candida]] on wet mount (adding 10% KOH destroys the cellular elements and facilitates recognition of budding yeast, pseudohyphae, and hyphae)
*Presence of [[Candida]] on [[wet mount]] (adding 10% KOH destroys the cellular elements and facilitates recognition of budding [[yeast]], [[pseudohyphae]], and [[hyphae]])
|-
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Lichen Sclerosus]]'''
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Lichen Sclerosus]]'''
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*Affects pre-pubertal and post-menopausal women, reflecting its nature of occurrence in low estrogen states<ref name="pmid23925660">{{cite journal| author=Zendell K, Edwards L| title=Lichen sclerosus with vaginal involvement: report of 2 cases and review of the literature. | journal=JAMA Dermatol | year= 2013 | volume= 149 | issue= 10 | pages= 1199-202 | pmid=23925660 | doi=10.1001/jamadermatol.2013.4885 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23925660  }} </ref>
*Affects [[pre-pubertal]] and [[post-menopausal]] women, reflecting its nature of occurrence in low [[estrogen]] states<ref name="pmid23925660">{{cite journal| author=Zendell K, Edwards L| title=Lichen sclerosus with vaginal involvement: report of 2 cases and review of the literature. | journal=JAMA Dermatol | year= 2013 | volume= 149 | issue= 10 | pages= 1199-202 | pmid=23925660 | doi=10.1001/jamadermatol.2013.4885 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23925660  }} </ref>
*Pruritus is the predominant symptom, burning with urination and dyspareunia can also be seen
*[[Pruritus]] is the predominant symptom, [[burning with urination]] and [[dyspareunia]] can also be seen
*On examination characteristically the lesions follow a figure of eight pattern affecting the areas around the vagina and anus
*On examination characteristically the lesions follow a figure of eight pattern affecting the areas around the [[vagina]] and [[anus]]
*Signs of active disease include white atrophic plaques with cigarette-paper wrinkling, petechiae, fissures and erosions can be demonstrated
*Signs of active disease include white atrophic plaques with cigarette-paper wrinkling, [[petechiae]], [[fissures]] and erosions can be demonstrated
*Examination findings of chronic disease include clitoral hood phimosis and labia minora resorption  
*Examination findings of chronic disease include clitoral hood [[phimosis]] and labia minora resorption  
*Diagnosis confirmed with skin punch biopsy
*Diagnosis confirmed with skin [[punch biopsy]]
|-
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Lichen Planus]]'''
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Lichen Planus]]'''
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*Affects pre-menopausal and post menopausal women<ref name="pmid20868406">{{cite journal| author=McPherson T, Cooper S| title=Vulval lichen sclerosus and lichen planus. | journal=Dermatol Ther | year= 2010 | volume= 23 | issue= 5 | pages= 523-32 | pmid=20868406 | doi=10.1111/j.1529-8019.2010.01355.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20868406  }} </ref>
*Affects pre-[[menopausal]] and post [[menopausal]] women<ref name="pmid20868406">{{cite journal| author=McPherson T, Cooper S| title=Vulval lichen sclerosus and lichen planus. | journal=Dermatol Ther | year= 2010 | volume= 23 | issue= 5 | pages= 523-32 | pmid=20868406 | doi=10.1111/j.1529-8019.2010.01355.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20868406  }} </ref>
*T-cell mediated inflammatory disease affecting mucosal membranes.
*[[T-cell]] mediated inflammatory disease affecting mucosal membranes
*In erosive form patients present with vulvar pain, dyspareunia and dysuria.
*In erosive form patients present with vulvar pain, [[dyspareunia]] and [[dysuria]]
*Non-erosive form presents with pruritus
*Non-erosive form presents with [[pruritus]]
*On examination appears lesions appear as red plaques or erosions, with overlying white violaceous or reticular plaques( Wickham Striae)
*On examination, lesions appear as red plaques or erosions, with overlying white violaceous or reticular plaques( Wickham Striae)
*Diagnosis confirmed by shave or punch biopsy
*Diagnosis confirmed by shave or [[punch biopsy]]
|-
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Lichen simplex chronicus]]'''  
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Lichen simplex chronicus]]'''  
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| style="padding: 5px 5px; background: #F5F5F5;" |  
*On examination leasion appear as thick, erythematous lichenified skin (epidermal thickening and accentuation of skin markings)
*On examination, the lesion appear as thick, [[erythematous]] lichenified skin (epidermal thickening and accentuation of skin markings)
*Due to long-term rubbing or scratching secondary to conditions such as recurrent yeast infections, contact dermatitis, psychiatric illness<ref name="pmid22594865">{{cite journal| author=Thorstensen KA, Birenbaum DL| title=Recognition and management of vulvar dermatologic conditions: lichen sclerosus, lichen planus, and lichen simplex chronicus. | journal=J Midwifery Womens Health | year= 2012 | volume= 57 | issue= 3 | pages= 260-75 | pmid=22594865 | doi=10.1111/j.1542-2011.2012.00175.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22594865  }} </ref>
*Due to long-term rubbing or scratching secondary to conditions such as recurrent [[yeast]] infections, [[contact dermatitis]], psychiatric illness<ref name="pmid22594865">{{cite journal| author=Thorstensen KA, Birenbaum DL| title=Recognition and management of vulvar dermatologic conditions: lichen sclerosus, lichen planus, and lichen simplex chronicus. | journal=J Midwifery Womens Health | year= 2012 | volume= 57 | issue= 3 | pages= 260-75 | pmid=22594865 | doi=10.1111/j.1542-2011.2012.00175.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22594865  }} </ref>
|-
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Contact dermatitis]]'''  
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Contact dermatitis]]'''  
| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" |  
*It could be allergic or irritant contact dermatitis
*It could be allergic or irritant contact dermatitis
*Presents with redness, swelling, and pruritus<ref name="pmid25608257">{{cite journal| author=Harper J, Zirwas M| title=Allergic contact dermatitis of the vagina and perineum: causes, incidence of, and differentiating factors. | journal=Clin Obstet Gynecol | year= 2015 | volume= 58 | issue= 1 | pages= 153-7 | pmid=25608257 | doi=10.1097/GRF.0000000000000094 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25608257  }} </ref>
*Presents with redness, swelling, and [[pruritus]]<ref name="pmid25608257">{{cite journal| author=Harper J, Zirwas M| title=Allergic contact dermatitis of the vagina and perineum: causes, incidence of, and differentiating factors. | journal=Clin Obstet Gynecol | year= 2015 | volume= 58 | issue= 1 | pages= 153-7 | pmid=25608257 | doi=10.1097/GRF.0000000000000094 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25608257  }} </ref>
*Ocassionally blistering and painful bright red swelling can be seen
*Ocassionally blistering and painful bright red swelling can be seen
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| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Vulvar intraepithelial neoplasm]]'''
| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Vulvar intraepithelial neoplasm]]'''
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*Bimodal peak is observed - between 40-44years and above 55years<ref name="pmid25987900">{{cite journal| author=Preti M, Igidbashian S, Costa S, Cristoforoni P, Mariani L, Origoni M et al.| title=VIN usual type-from the past to the future. | journal=Ecancermedicalscience | year= 2015 | volume= 9 | issue=  | pages= 531 | pmid=25987900 | doi=10.3332/ecancer.2015.531 | pmc=4431399 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25987900  }} </ref>
*Bimodal peak is observed between 40-44 years and above 55 years<ref name="pmid25987900">{{cite journal| author=Preti M, Igidbashian S, Costa S, Cristoforoni P, Mariani L, Origoni M et al.| title=VIN usual type-from the past to the future. | journal=Ecancermedicalscience | year= 2015 | volume= 9 | issue=  | pages= 531 | pmid=25987900 | doi=10.3332/ecancer.2015.531 | pmc=4431399 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25987900  }} </ref>
*Red, white, or dark raised or eroded multifocal lesions <ref name="pmid26133495">{{cite journal| author=Nelson EL, Bogliatto F, Stockdale CK| title=Vulvar Intraepithelial Neoplasia (VIN) and Condylomata. | journal=Clin Obstet Gynecol | year= 2015 | volume= 58 | issue= 3 | pages= 512-25 | pmid=26133495 | doi=10.1097/GRF.0000000000000132 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26133495  }} </ref><ref name="pmid24399036">{{cite journal| author=Reyes MC, Cooper K| title=An update on vulvar intraepithelial neoplasia: terminology and a practical approach to diagnosis. | journal=J Clin Pathol | year= 2014 | volume= 67 | issue= 4 | pages= 290-4 | pmid=24399036 | doi=10.1136/jclinpath-2013-202117 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24399036  }} </ref>
*Red, white, or dark raised or eroded multifocal lesions <ref name="pmid26133495">{{cite journal| author=Nelson EL, Bogliatto F, Stockdale CK| title=Vulvar Intraepithelial Neoplasia (VIN) and Condylomata. | journal=Clin Obstet Gynecol | year= 2015 | volume= 58 | issue= 3 | pages= 512-25 | pmid=26133495 | doi=10.1097/GRF.0000000000000132 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26133495  }} </ref><ref name="pmid24399036">{{cite journal| author=Reyes MC, Cooper K| title=An update on vulvar intraepithelial neoplasia: terminology and a practical approach to diagnosis. | journal=J Clin Pathol | year= 2014 | volume= 67 | issue= 4 | pages= 290-4 | pmid=24399036 | doi=10.1136/jclinpath-2013-202117 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24399036  }} </ref>
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Vulvar cancer|Vulvar Cancer]]'''
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Vulvar cancer|Vulvar Cancer]]'''
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*Presents as a solitary ulcer with raised or indurated edge
*Presents as a solitary [[ulcer]] with raised or [[indurated]] edge
*Histologically it can be a melanoma, squamous cell carcinoma, basal cell carcinoma or neuroendocrine cancer<ref name="pmid25930015">{{cite journal| author=Chokoeva AA, Tchernev G, Castelli E, Orlando E, Verma SB, Grebe M et al.| title=Vulvar cancer: a review for dermatologists. | journal=Wien Med Wochenschr | year= 2015 | volume= 165 | issue= 7-8 | pages= 164-77 | pmid=25930015 | doi=10.1007/s10354-015-0354-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25930015  }} </ref>
*Histologically it can be a [[melanoma]], [[squamous cell carcinoma]], [[basal cell carcinoma]] or neuroendocrine cancer<ref name="pmid25930015">{{cite journal| author=Chokoeva AA, Tchernev G, Castelli E, Orlando E, Verma SB, Grebe M et al.| title=Vulvar cancer: a review for dermatologists. | journal=Wien Med Wochenschr | year= 2015 | volume= 165 | issue= 7-8 | pages= 164-77 | pmid=25930015 | doi=10.1007/s10354-015-0354-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25930015  }} </ref>
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| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Extramammary Paget's disease|Extramammary Paget disease]]'''
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Extramammary Paget's disease|Extramammary Paget disease]]'''
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*Seen in postmenopausal women
*Seen in [[postmenopausal]] women
*On examination it appears as a erythematous plaque with typical white scaling known as “cake-icing scaling”<ref name="van der LindenMeeuwis2016">{{cite journal|last1=van der Linden|first1=M.|last2=Meeuwis|first2=K.A.P.|last3=Bulten|first3=J.|last4=Bosse|first4=T.|last5=van Poelgeest|first5=M.I.E.|last6=de Hullu|first6=J.A.|title=Paget disease of the vulva|journal=Critical Reviews in Oncology/Hematology|volume=101|year=2016|pages=60–74|issn=10408428|doi=10.1016/j.critrevonc.2016.03.008}}</ref>
*On examination it appears as a [[erythematous]] [[plaque]] with typical white scaling known as “cake-icing scaling”<ref name="van der LindenMeeuwis2016">{{cite journal|last1=van der Linden|first1=M.|last2=Meeuwis|first2=K.A.P.|last3=Bulten|first3=J.|last4=Bosse|first4=T.|last5=van Poelgeest|first5=M.I.E.|last6=de Hullu|first6=J.A.|title=Paget disease of the vulva|journal=Critical Reviews in Oncology/Hematology|volume=101|year=2016|pages=60–74|issn=10408428|doi=10.1016/j.critrevonc.2016.03.008}}</ref>
*Biopsy is characterized by the presence of intraepithelial mucin-producing neoplastic cells known as Paget cells<ref name="pmid25830993">{{cite journal| author=Lopes Filho LL, Lopes IM, Lopes LR, Enokihara MM, Michalany AO, Matsunaga N| title=Mammary and extramammary Paget's disease. | journal=An Bras Dermatol | year= 2015 | volume= 90 | issue= 2 | pages= 225-31 | pmid=25830993 | doi=10.1590/abd1806-4841.20153189 | pmc=4371672 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25830993  }} </ref>
*[[Biopsy]] is characterized by the presence of intraepithelial mucin-producing [[neoplastic]] cells known as [[Paget cells]]<ref name="pmid25830993">{{cite journal| author=Lopes Filho LL, Lopes IM, Lopes LR, Enokihara MM, Michalany AO, Matsunaga N| title=Mammary and extramammary Paget's disease. | journal=An Bras Dermatol | year= 2015 | volume= 90 | issue= 2 | pages= 225-31 | pmid=25830993 | doi=10.1590/abd1806-4841.20153189 | pmc=4371672 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25830993  }} </ref>
|}
|}


==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==
===Natural History===
===Natural History===
Atrophic vaginitis is a chronic progressive medical problem affecting postmenopausal women and in younger women with low estrogen levels. Women present with vaginal dryness, pruritus, urinary disturbances and dyspareunia.<ref>{{cite journal|title=Management of symptomatic vulvovaginal atrophy|journal=Menopause: The Journal of The North American Menopause Society|volume=20|issue=9|year=2013|pages=888–902|issn=1072-3714|doi=10.1097/GME.0b013e3182a122c2}}</ref>
Atrophic vaginitis is a chronic progressive medical problem affecting [[postmenopausal]] women and in younger women with low [[estrogen]] levels. Women present with vaginal dryness, [[pruritus]], urinary disturbances and [[dyspareunia]].<ref>{{cite journal|title=Management of symptomatic vulvovaginal atrophy|journal=Menopause: The Journal of The North American Menopause Society|volume=20|issue=9|year=2013|pages=888–902|issn=1072-3714|doi=10.1097/GME.0b013e3182a122c2}}</ref>
 
===Prognosis===
===Prognosis===
Atrophic vagnitis is a chronic disease and requires continuous treatment with estrogen or other alternatives. Majority of the patients have significant resolution of the symptoms with treatment, however the symptoms recur once the treatment is stopped.<ref>{{cite journal|title=Management of symptomatic vulvovaginal atrophy|journal=Menopause: The Journal of The North American Menopause Society|volume=20|issue=9|year=2013|pages=888–902|issn=1072-3714|doi=10.1097/GME.0b013e3182a122c2}}</ref>
Atrophic vagnitis is a chronic disease and requires continuous treatment with [[estrogen]] or other alternatives. Majority of the patients have significant resolution of the symptoms with treatment, however the symptoms recur once the treatment is stopped.<ref>{{cite journal|title=Management of symptomatic vulvovaginal atrophy|journal=Menopause: The Journal of The North American Menopause Society|volume=20|issue=9|year=2013|pages=888–902|issn=1072-3714|doi=10.1097/GME.0b013e3182a122c2}}</ref>


===Complications===
===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><ref name="DiBonaventuraLuo2015">{{cite journal|last1=DiBonaventura|first1=Marco|last2=Luo|first2=Xuemei|last3=Moffatt|first3=Margaret|last4=Bushmakin|first4=Andrew G.|last5=Kumar|first5=Maya|last6=Bobula|first6=Joel|title=The Association Between Vulvovaginal Atrophy Symptoms and Quality of Life Among Postmenopausal Women in the United States and Western Europe|journal=Journal of Women's Health|volume=24|issue=9|year=2015|pages=713–722|issn=1540-9996|doi=10.1089/jwh.2014.5177}}</ref>
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><ref name="DiBonaventuraLuo2015">{{cite journal|last1=DiBonaventura|first1=Marco|last2=Luo|first2=Xuemei|last3=Moffatt|first3=Margaret|last4=Bushmakin|first4=Andrew G.|last5=Kumar|first5=Maya|last6=Bobula|first6=Joel|title=The Association Between Vulvovaginal Atrophy Symptoms and Quality of Life Among Postmenopausal Women in the United States and Western Europe|journal=Journal of Women's Health|volume=24|issue=9|year=2015|pages=713–722|issn=1540-9996|doi=10.1089/jwh.2014.5177}}</ref>
*If left untreated the greatest impact is the lack of sexual enjoyment and other effects such as sleep disturbances, general enjoyment of life, and temperament.<ref name="SimonKokot-Kierepa2013">{{cite journal|last1=Simon|first1=James A.|last2=Kokot-Kierepa|first2=Marta|last3=Goldstein|first3=Jeffrey|last4=Nappi|first4=Rossella E.|title=Vaginal health in the United States|journal=Menopause|volume=20|issue=10|year=2013|pages=1043–1048|issn=1072-3714|doi=10.1097/GME.0b013e318287342d}}</ref>
*If left untreated, the greatest impact is the lack of sexual enjoyment and other effects such as [[sleep disturbances]].<ref name="SimonKokot-Kierepa2013">{{cite journal|last1=Simon|first1=James A.|last2=Kokot-Kierepa|first2=Marta|last3=Goldstein|first3=Jeffrey|last4=Nappi|first4=Rossella E.|title=Vaginal health in the United States|journal=Menopause|volume=20|issue=10|year=2013|pages=1043–1048|issn=1072-3714|doi=10.1097/GME.0b013e318287342d}}</ref>
*Stress urinary [[incontinence]]
*Stress urinary [[incontinence]]
*Urge [[incontinence]]
*Urge [[incontinence]]
Line 189: Line 191:
===History and Symptoms===
===History and Symptoms===
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>
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]]
**Vaginal irritation
**Vaginal irritation
**Vaginal itching
**Vaginal [[pruritus]]
**Yellowish or brown vaginal discharge
**Yellowish or brown [[vaginal discharge]]
*Sexual symptoms:
*'''Sexual symptoms:'''
**Painful sexual intercourse ([[dyspareunia]])
**Painful sexual intercourse ([[dyspareunia]])
**Postcoital bleeding
**Postcoital bleeding
**Loss of bleeding
**Lack of arousal
**Loss of arousal
**[[Pelvic pain]]
**Pelvic pain
*'''Urological symptoms:'''
*Urological symptoms:
**Burning on urination ([[dysuria]])
**Burning on urination ([[dysuria]])
**Urinary frequency
**Increased [[Urinary frequency]]
**Urinary urgency
**Increased [[Urinary urgency]]
**[[Nocturia]]
**[[Nocturia]]
**Urinary [[incontinence]]
**Urinary [[incontinence]]
**Recurrent urinary tract infections ([[UTI]])
**[[Urinary tract infection|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 includes a general inspection of the [[external genitalia]], a [[speculum]] examination.<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]].  
*Physical examination in women with atrophic vaginitis begins with inspection of the [[external genitalia]]. Findings include 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. Other findings include increased friability, inflamed epithelium with patchy erythema and petechiae.  
*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. Other findings include increased friability, inflamed [[epithelium]] with patchy [[erythema]] and [[petechiae]].  
*Other findings may include: [[pelvic organ prolapse]], such as [[cystocele]] and/or [[rectocele]], urethral polyps or eversion of the urethral mucosa.
*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===
====Assessment of Vaginal Atrophy====
====Assessment of Vaginal Atrophy====
*'''Vaginal Cytology:''' It demonstrates a decrease in the superficial squamous cells and an increased parabasal cells.<ref name="pmid10082300">{{cite journal| author=van der Laak JA, Schijf CP, Kerstens HM, Heijnen-Wijnen TH, de Wilde PC, Hanselaar GJ| title=Development and validation of a computerized cytomorphometric method to assess the maturation of vaginal epithelial cells. | journal=Cytometry | year= 1999 | volume= 35 | issue= 3 | pages= 196-202 | pmid=10082300 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10082300  }}</ref>
*'''Vaginal Cytology:''' It demonstrates a decrease in the superficial [[squamous]] cells and an increased parabasal cells.<ref name="pmid10082300">{{cite journal| author=van der Laak JA, Schijf CP, Kerstens HM, Heijnen-Wijnen TH, de Wilde PC, Hanselaar GJ| title=Development and validation of a computerized cytomorphometric method to assess the maturation of vaginal epithelial cells. | journal=Cytometry | year= 1999 | volume= 35 | issue= 3 | pages= 196-202 | pmid=10082300 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10082300  }}</ref>
*'''Vaginal Maturation Index(VMI):''' It represents the percentage of the parabasal, intermediate and superficial squamous cells. It is for example represented and read from left to right as follows ; 0/35/65-it represents 0% parabasal cells, 35% intermediate cells and 65% superficial cells. A shift to the left indicates vaginal atrophy.<ref name="pmid10507070">{{cite journal| author=McEndree B| title=Clinical application of the vaginal maturation index. | journal=Nurse Pract | year= 1999 | volume= 24 | issue= 9 | pages= 48, 51-2, 55-6 | pmid=10507070 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10507070  }}</ref>
*'''Vaginal Maturation Index(VMI):''' It represents the percentage of the parabasal, intermediate and superficial [[squamous]] cells. It read from left to right as follows, for example if its represented as 0/35/65-it means the smear has 0% parabasal cells, 35% intermediate cells and 65% superficial cells. A shift to the left indicates vaginal atrophy.<ref name="pmid10507070">{{cite journal| author=McEndree B| title=Clinical application of the vaginal maturation index. | journal=Nurse Pract | year= 1999 | volume= 24 | issue= 9 | pages= 48, 51-2, 55-6 | pmid=10507070 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10507070  }}</ref>
*'''Vaginal Maturation Value (VMV):''' It is calcualted using a formula: 0 * %parabasal cells + 0.5 * %intermediate cells + 1.0 * superficial cells divided by 2. A lower VMV indicates a low number of superficial cells indicating hypoestrogenic state.<ref name="WeberLimpens2014">{{cite journal|last1=Weber|first1=M. A.|last2=Limpens|first2=J.|last3=Roovers|first3=J. P. W. R.|title=Assessment of vaginal atrophy: a review|journal=International Urogynecology Journal|volume=26|issue=1|year=2014|pages=15–28|issn=0937-3462|doi=10.1007/s00192-014-2464-0}}</ref>
*'''Vaginal Maturation Value (VMV):''' It is calculated using a formula: 0 * %parabasal cells + 0.5 * %intermediate cells + 1.0 * superficial cells divided by 2.  
*'''Vaginal pH''' : Normal vaginal pH is acidic and is maintained by the lactobacillus flora by the breakdown of glucose (from the vaginal epithelial cell glycogen-the level of which is based on the estrogen) to lactic acid.
**A lower VMV indicates a low number of superficial cells indicating [[hypoestrogenic]] state.<ref name="WeberLimpens2014">{{cite journal|last1=Weber|first1=M. A.|last2=Limpens|first2=J.|last3=Roovers|first3=J. P. W. R.|title=Assessment of vaginal atrophy: a review|journal=International Urogynecology Journal|volume=26|issue=1|year=2014|pages=15–28|issn=0937-3462|doi=10.1007/s00192-014-2464-0}}</ref>  
**In lower estrogen states the vaginal pH is typically greater then 5; higher than normal due to lower levels of glycogen in the epithelial cells. It is a useful and inexpensive test in the absence of bacterial vaginosis to indicate vaginal atrophy.<ref name="pmid9215184">{{cite journal| author=Caillouette JC, Sharp CF, Zimmerman GJ, Roy S| title=Vaginal pH as a marker for bacterial pathogens and menopausal status. | journal=Am J Obstet Gynecol | year= 1997 | volume= 176 | issue= 6 | pages= 1270-5; discussion 1275-7 | pmid=9215184 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9215184  }}</ref>
*'''Vaginal [[pH]]''' : Normal vaginal [[pH]] is acidic and is maintained by the [[lactobacillus]] flora by the breakdown of [[glucose]] (from the vaginal epithelial cell [[glycogen]]-the level of which is based on the [[estrogen]]) to [[lactic acid]].
*'''Wet mount of vaginal smear''' : Demonstrates the paucity of Lactobacillus.
**In lower [[estrogen]] states, the vaginal [[pH]] is typically greater then 5; higher than normal due to lower levels of [[glycogen]] in the epithelial cells. It is a useful and inexpensive test in the absence of bacterial vaginosis to indicate vaginal atrophy.<ref name="pmid9215184">{{cite journal| author=Caillouette JC, Sharp CF, Zimmerman GJ, Roy S| title=Vaginal pH as a marker for bacterial pathogens and menopausal status. | journal=Am J Obstet Gynecol | year= 1997 | volume= 176 | issue= 6 | pages= 1270-5; discussion 1275-7 | pmid=9215184 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9215184  }}</ref>
*'''FSH Level''': Estimation of FSH is not neccessary for the diagnosis of hypoestrogenic state as alkaline pH of vaginal secretions is equally sensitive.<ref name="pmid15167829">{{cite journal| author=Roy S, Caillouette JC, Roy T, Faden JS| title=Vaginal pH is similar to follicle-stimulating hormone for menopause diagnosis. | journal=Am J Obstet Gynecol | year= 2004 | volume= 190 | issue= 5 | pages= 1272-7 | pmid=15167829 | doi=10.1016/j.ajog.2003.12.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15167829  }} </ref>
*'''[[Wet mount]] of vaginal smear''' : Demonstrates the paucity of [[lactobacillus]].
*'''[[FSH]] Level''': Estimation of [[FSH]] is not neccessary for the diagnosis of [[hypoestrogenic]] state as [[alkaline]] pH of vaginal secretions is equally sensitive.<ref name="pmid15167829">{{cite journal| author=Roy S, Caillouette JC, Roy T, Faden JS| title=Vaginal pH is similar to follicle-stimulating hormone for [[menopause]] diagnosis. | journal=Am J Obstet Gynecol | year= 2004 | volume= 190 | issue= 5 | pages= 1272-7 | pmid=15167829 | doi=10.1016/j.ajog.2003.12.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15167829  }} </ref>


===Ultrasound===
===Ultrasound===
An ultrasound of the uterus may demonstrate thinning of the endometrium lining to 4-5mm.
An [[ultrasound]] of the [[uterus]] may demonstrate thinning of the [[endometrium]] lining to 4-5mm.<ref name="pmid27472999">{{cite journal| author=Gandhi J, Chen A, Dagur G, Suh Y, Smith N, Cali B et al.| title=Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. | journal=Am J Obstet Gynecol | year= 2016 | volume= 215 | issue= 6 | pages= 704-711 | pmid=27472999 | doi=10.1016/j.ajog.2016.07.045 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27472999  }} </ref>


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
Atrophic vaginitis is a chronic condition which mandates continuous treatment. The choice of therapy is based on the severity of the symptoms and associated factors such as history of hormone dependent cancer. <ref>{{cite journal|title=Management of symptomatic vulvovaginal atrophy|journal=Menopause: The Journal of The North American Menopause Society|volume=20|issue=9|year=2013|pages=888–902|issn=1072-3714|doi=10.1097/GME.0b013e3182a122c2}}</ref><ref name="pmid26444994">{{cite journal| author=Stuenkel CA, Davis SR, Gompel A, Lumsden MA, Murad MH, Pinkerton JV et al.| title=Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. | journal=J Clin Endocrinol Metab | year= 2015 | volume= 100 | issue= 11 | pages= 3975-4011 | pmid=26444994 | doi=10.1210/jc.2015-2236 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26444994  }}</ref>  
Atrophic vaginitis is a chronic condition requiring continuous treatment. The choice of therapy is based on the severity of the symptoms and associated factors such as history of [[hormone]] dependent cancer. <ref>{{cite journal|title=Management of symptomatic vulvovaginal atrophy|journal=Menopause: The Journal of The North American Menopause Society|volume=20|issue=9|year=2013|pages=888–902|issn=1072-3714|doi=10.1097/GME.0b013e3182a122c2}}</ref><ref name="pmid26444994">{{cite journal| author=Stuenkel CA, Davis SR, Gompel A, Lumsden MA, Murad MH, Pinkerton JV et al.| title=Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. | journal=J Clin Endocrinol Metab | year= 2015 | volume= 100 | issue= 11 | pages= 3975-4011 | pmid=26444994 | doi=10.1210/jc.2015-2236 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26444994  }}</ref>  
*In patients with mild symptoms lubricants are the first line therapeutic choice to relieve symptoms.<ref name="pmid27577677">{{cite journal| author=Lethaby A, Ayeleke RO, Roberts H| title=Local oestrogen for vaginal atrophy in postmenopausal women. | journal=Cochrane Database Syst Rev | year= 2016 | volume=  | issue= 8 | pages= CD001500 | pmid=27577677 | doi=10.1002/14651858.CD001500.pub3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27577677  }}</ref>
*In patients with mild symptoms, the vaginal [[lubricants]] are the first line therapeutic choice to relieve symptoms.<ref name="pmid27577677">{{cite journal| author=Lethaby A, Ayeleke RO, Roberts H| title=Local oestrogen for vaginal atrophy in postmenopausal women. | journal=Cochrane Database Syst Rev | year= 2016 | volume=  | issue= 8 | pages= CD001500 | pmid=27577677 | doi=10.1002/14651858.CD001500.pub3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27577677  }}</ref>
*In patients with moderate to severe symptoms unresponsive to lubricants topical estrogen or oral estrogen therapy is preferred. In patients with menopause topical agents are preferred over systemic.  
*In patients with moderate to severe symptoms unresponsive to [[lubricants]], the topical [[estrogen]] or oral [[estrogen]] therapy is preferred. In patients with [[menopause]], the [[topical]] agents are preferred over [[systemic]] therapy.  
*In patients with history of hormone dependent cancer, discuss the risks and benefits with the patient and the oncologist before initiation of therapy.  
*In patients with the history of [[harmone]] dependent [[cancer]], discuss the risks and benefits with the patient and the oncologist before initiation of therapy.  
*Progesterone is not indicated in patients with topical low dose estrogen therapy, however endometrial safety studies are lacking in this group who receive treatment greater than a year.  
*Progesterone is not indicated in patients with topical low dose [[estrogen]] therapy, however [[endometrial]] safety studies are lacking in this group who receive treatment greater than a year.  
*Patients at a higher risk of developing endometrial cancer secondary to estrogen therapy, annual transvaginal ultrasound is recommended .  
*Patients at a higher risk of developing [[endometrial cancer]] secondary to [[estrogen]] therapy, annual [[transvaginal ultrasound]] is recommended .  
*All the patients with post-menopausal bleeding with a uterus, should be evaluated with transvaginal ultrasound and endometrial biopsy.  
*All the patients with [[post-menopausal]] bleeding with a [[uterus]], should be evaluated with [[transvaginal ultrasound]] and [[endometrial biopsy]].  
*The following table is the description of available options for the treatment of Atrophic vaginitis<ref name="pmid24601810">{{cite journal| author=Domoney C| title=Treatment of vaginal atrophy. | journal=Womens Health (Lond) | year= 2014 | volume= 10 | issue= 2 | pages= 191-200 | pmid=24601810 | doi=10.2217/whe.14.9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24601810  }} </ref>:  
*The following table is the description of available options for the treatment of atrophic vaginitis<ref name="pmid24601810">{{cite journal| author=Domoney C| title=Treatment of vaginal atrophy. | journal=Womens Health (Lond) | year= 2014 | volume= 10 | issue= 2 | pages= 191-200 | pmid=24601810 | doi=10.2217/whe.14.9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24601810  }} </ref>:  
{| class="wikitable"
{| class="wikitable"
!Treatment Modality
!Treatment Modality
Line 243: Line 245:
!Limitations
!Limitations
|-
|-
|Topical Estrogen<ref name="pmid17438512">{{cite journal| author=North American Menopause Society| title=The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. | journal=Menopause | year= 2007 | volume= 14 | issue= 3 Pt 1 | pages= 355-69; quiz 370-1 | pmid=17438512 | doi=10.1097/gme.0b013e31805170eb | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17438512  }} </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="pmid2498619">{{cite journal |vauthors=Holmgren PA, Lindskog M, von Schoultz B |title=Vaginal rings for continuous low-dose release of oestradiol in the treatment of urogenital atrophy |journal=Maturitas |volume=11 |issue=1 |pages=55–63 |year=1989 |pmid=2498619 |doi= |url=}}</ref>
|Topical [[Estrogen]]<ref name="pmid17438512">{{cite journal| author=North American Menopause Society| title=The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. | journal=Menopause | year= 2007 | volume= 14 | issue= 3 Pt 1 | pages= 355-69; quiz 370-1 | pmid=17438512 | doi=10.1097/gme.0b013e31805170eb | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17438512  }} </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="pmid2498619">{{cite journal |vauthors=Holmgren PA, Lindskog M, von Schoultz B |title=Vaginal rings for continuous low-dose release of oestradiol in the treatment of urogenital atrophy |journal=Maturitas |volume=11 |issue=1 |pages=55–63 |year=1989 |pmid=2498619 |doi= |url=}}</ref>
(Creams and Estradiol releasing vaginal rings)
(Creams and [[Estradiol]] releasing [[vaginal rings]])
|
|
*Restores vaginal epithelium and associated vaginal vasculature<ref name="PalaciosCastelo-Branco2015">{{cite journal|last1=Palacios|first1=Santiago|last2=CasteloBranco|first2=Camil|last3=Currie|first3=Heather|last4=Mijatovic|first4=Velja|last5=Nappi|first5=Rossella E.|last6=Simon|first6=James|last7=Rees|first7=Margaret|title=Update on management of genitourinary syndrome of menopause: A practical guide|journal=Maturitas|volume=82|issue=3|year=2015|pages=308–313|issn=03785122|doi=10.1016/j.maturitas.2015.07.020}}</ref>
*Restores vaginal [[epithelium]] and associated vaginal [[vasculature]]<ref name="PalaciosCastelo-Branco2015">{{cite journal|last1=Palacios|first1=Santiago|last2=CasteloBranco|first2=Camil|last3=Currie|first3=Heather|last4=Mijatovic|first4=Velja|last5=Nappi|first5=Rossella E.|last6=Simon|first6=James|last7=Rees|first7=Margaret|title=Update on management of genitourinary syndrome of menopause: A practical guide|journal=Maturitas|volume=82|issue=3|year=2015|pages=308–313|issn=03785122|doi=10.1016/j.maturitas.2015.07.020}}</ref>
*Improves vaginal secretions
*Improves vaginal secretions
*Lowers vaginal pH and restores healthy vaginal flora
*Lowers vaginal [[pH]] and restores healthy vaginal flora
*Relieves urinary symptoms
*Relieves urinary symptoms
*Effective resolution of dyspareunia, vaginal itching, and dryness<ref name="pmid17054136">{{cite journal| author=Suckling J, Lethaby A, Kennedy R| title=Local oestrogen for vaginal atrophy in postmenopausal women. | journal=Cochrane Database Syst Rev | year= 2006 | volume=  | issue= 4 | pages= CD001500 | pmid=17054136 | doi=10.1002/14651858.CD001500.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17054136  }} </ref>
*Effective resolution of [[dyspareunia]], vaginal [[itching]], and dryness<ref name="pmid17054136">{{cite journal| author=Suckling J, Lethaby A, Kennedy R| title=Local oestrogen for vaginal atrophy in postmenopausal women. | journal=Cochrane Database Syst Rev | year= 2006 | volume=  | issue= 4 | pages= CD001500 | pmid=17054136 | doi=10.1002/14651858.CD001500.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17054136  }} </ref>
|
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*No systemic absorption
*No systemic absorption
Line 256: Line 258:
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*Creams can be messy to use
*Creams can be messy to use
*Rings are expelled in patients with cystocele and rectocele
*Rings are expelled in patients with [[cystocele]] and [[rectocele]]
*Side effects include vaginal secretion, vaginal spotting, and genital pruritus
*Side effects include vaginal secretion, vaginal spotting, and genital pruritus
|-
|-
|Oral Estrogen Therapy
|Oral [[Estrogen]] Therapy
|
|
In addition to the changes with topical estrogen other actions include:
In addition to the changes with topical [[estrogen]] other actions include:
*Relief from hot flashes and protection from osteoporosis
*Relief from [[hot flashes]] and protection from [[osteoporosis]]


|Treats menopausal symptoms like hot flashes
|
|
*Adverse effects include :breast tenderness and/or enlargement, vaginal bleeding or spotting, nausea, and weight gain
* Treats [[menopausal]] symptoms like [[hot flashes]]
*Contraindications include: known or suspected cases of breast cancer, estrogen-dependent cancers, undiagnosed vaginal bleeding, history of thromboembolism, endometrial hyperplasia or cancer, hypertension, hyperlipidemia, liver disease,history of stroke, venothrombotic events, coronary heart disease, pregnancy, smoking in those age >35 years, migraines with neurologic symptoms, and acute cholecystitis/cholangitis.
|
*Adverse effects include: Breast [[tenderness]] with or without enlargement, [[vaginal bleeding]] or spotting, [[nausea]], and weight gain
*Contraindications to estrogen inlcude: known or suspected cases of [[breast cancer]], estrogen-dependent cancers, undiagnosed [[vaginal bleeding]], history of [[thromboembolism]], [[endometrial hyperplasia]] or [[Endometrial cancer|cancer]], [[hypertension]], [[hyperlipidemia]], [[Liver diseases|liver disease]],history of [[stroke]], [[coronary heart disease]], [[pregnancy]], [[smoking]] in those age >35 years, [[migraines]] with neurologic symptoms, and acute [[cholecystitis]]/[[cholangitis]].
|-
|-
|Selective estrogen receptor modulator
|Selective estrogen receptor modulator
Ospemifene<ref name="pmid25052122">{{cite journal| author=McLendon AN, Clinard VB, Woodis CB| title=Ospemifene for the treatment of vulvovaginal atrophy and dyspareunia in postmenopausal women. | journal=Pharmacotherapy | year= 2014 | volume= 34 | issue= 10 | pages= 1050-60 | pmid=25052122 | doi=10.1002/phar.1465 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25052122  }} </ref>
[[Ospemifene]]<ref name="pmid25052122">{{cite journal| author=McLendon AN, Clinard VB, Woodis CB| title=Ospemifene for the treatment of vulvovaginal atrophy and dyspareunia in postmenopausal women. | journal=Pharmacotherapy | year= 2014 | volume= 34 | issue= 10 | pages= 1050-60 | pmid=25052122 | doi=10.1002/phar.1465 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25052122 }} </ref>
|
*Safe in treating [[vulvovaginal atrophy]]
*Treats [[dyspareunia]] by improving vaginal structure and [[pH]]
|
* Less than 1% risk of developing [[endometrial hyperplasia]] after treatment for 52 weeks<ref name="pmid25419123">{{cite journal| author=Wurz GT, Kao CJ, DeGregorio MW| title=Safety and efficacy of ospemifene for the treatment of dyspareunia associated with vulvar and vaginal atrophy due to menopause. | journal=Clin Interv Aging | year= 2014 | volume= 9 | issue=  | pages= 1939-50 | pmid=25419123 | doi=10.2147/CIA.S73753 | pmc=4235480 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25419123 }} </ref>
|
|
*Safe in treating vulvovaginal atrophy
* Increased risk of [[venous thromboembolism]]
*Treats dyspareunia by improving vaginal structure and pH
|Less than 1% risk of developing endometrial hyperplasia after treatment for 52weeks<ref name="pmid25419123">{{cite journal| author=Wurz GT, Kao CJ, DeGregorio MW| title=Safety and efficacy of ospemifene for the treatment of dyspareunia associated with vulvar and vaginal atrophy due to menopause. | journal=Clin Interv Aging | year= 2014 | volume= 9 | issue=  | pages= 1939-50 | pmid=25419123 | doi=10.2147/CIA.S73753 | pmc=4235480 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25419123  }} </ref>
|Increased risk of venous thromboembolism
|-
|-
|Laser Therapy
|[[Laser]] Therapy
|
|
*Fractional microablative carbon-dioxide lazer improves vascularity, glycogen storage, extracellular matrix production cellular proliferation<ref name="pmid27558459">{{cite journal| author=Athanasiou S, Pitsouni E, Antonopoulou S, Zacharakis D, Salvatore S, Falagas ME et al.| title=The effect of microablative fractional CO2 laser on vaginal flora of postmenopausal women. | journal=Climacteric | year= 2016 | volume= 19 | issue= 5 | pages= 512-8 | pmid=27558459 | doi=10.1080/13697137.2016.1212006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27558459  }} </ref>
*Fractional microablative [[carbondioxide]] [[laser]] improves vascularity, [[glycogen]] storage, [[extracellular matrix]] production cellular proliferation<ref name="pmid27558459">{{cite journal| author=Athanasiou S, Pitsouni E, Antonopoulou S, Zacharakis D, Salvatore S, Falagas ME et al.| title=The effect of microablative fractional CO2 laser on vaginal flora of postmenopausal women. | journal=Climacteric | year= 2016 | volume= 19 | issue= 5 | pages= 512-8 | pmid=27558459 | doi=10.1080/13697137.2016.1212006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27558459  }} </ref>
*Impreovement of vaginal epithelial thickness and viability<ref name="pmid27823733">{{cite journal| author=Pitsouni E, Grigoriadis T, Tsiveleka A, Zacharakis D, Salvatore S, Athanasiou S| title=Microablative fractional CO2-laser therapy and the genitourinary syndrome of menopause: An observational study. | journal=Maturitas | year= 2016 | volume= 94 | issue=  | pages= 131-136 | pmid=27823733 | doi=10.1016/j.maturitas.2016.09.012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27823733  }} </ref>
*Improvement of vaginal epithelial thickness and viability<ref name="pmid27823733">{{cite journal| author=Pitsouni E, Grigoriadis T, Tsiveleka A, Zacharakis D, Salvatore S, Athanasiou S| title=Microablative fractional CO2-laser therapy and the genitourinary syndrome of menopause: An observational study. | journal=Maturitas | year= 2016 | volume= 94 | issue=  | pages= 131-136 | pmid=27823733 | doi=10.1016/j.maturitas.2016.09.012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27823733  }} </ref>
|
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*Improvement of symptoms sustained at 12 weeks after therapy
*Improvement of symptoms sustained at 12 weeks after therapy
*Improved sexual activity<ref name="pmid25333211">{{cite journal| author=Salvatore S, Nappi RE, Parma M, Chionna R, Lagona F, Zerbinati N et al.| title=Sexual function after fractional microablative CO₂ laser in women with vulvovaginal atrophy. | journal=Climacteric | year= 2015 | volume= 18 | issue= 2 | pages= 219-25 | pmid=25333211 | doi=10.3109/13697137.2014.975197 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25333211  }} </ref>
*Improved sexual activity<ref name="pmid25333211">{{cite journal| author=Salvatore S, Nappi RE, Parma M, Chionna R, Lagona F, Zerbinati N et al.| title=Sexual function after fractional microablative CO₂ laser in women with vulvovaginal atrophy. | journal=Climacteric | year= 2015 | volume= 18 | issue= 2 | pages= 219-25 | pmid=25333211 | doi=10.3109/13697137.2014.975197 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25333211  }} </ref>
|Lack of longterm evidence on efficacy and safety<ref name="pmid26323234">{{cite journal| author=Hutchinson-Colas J, Segal S| title=Genitourinary syndrome of menopause and the use of laser therapy. | journal=Maturitas | year= 2015 | volume= 82 | issue= 4 | pages= 342-5 | pmid=26323234 | doi=10.1016/j.maturitas.2015.08.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26323234  }}</ref>
|Lack of long term evidence on efficacy and safety<ref name="pmid26323234">{{cite journal| author=Hutchinson-Colas J, Segal S| title=Genitourinary syndrome of menopause and the use of laser therapy. | journal=Maturitas | year= 2015 | volume= 82 | issue= 4 | pages= 342-5 | pmid=26323234 | doi=10.1016/j.maturitas.2015.08.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26323234  }}</ref>
*Common adverse effect is hot flashes
*Common adverse effect is [[hot flashes]]
*Contraindicated in patients with DVT
*Contraindicated in patients with [[Deep vein thrombosis economy class syndrome|DVT]]
|-
|-
|Tibolone
|[[Tibolone]]
Synthetic steriod
Synthetic steriod
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Line 295: Line 300:
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*Improvement of urinary symptoms
*Improvement of urinary symptoms
*No endometrial hyperplasia <ref name="pmid19140498">{{cite journal| author=Szlendak-Sauer K, Wierzba W, Radowicki S| title=[The influence of a tibolone therapy on endometrium in postmenopausal women]. | journal=Ginekol Pol | year= 2008 | volume= 79 | issue= 11 | pages= 758-61 | pmid=19140498 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19140498  }} </ref>   
*No [[endometrial hyperplasia]] <ref name="pmid19140498">{{cite journal| author=Szlendak-Sauer K, Wierzba W, Radowicki S| title=[The influence of a tibolone therapy on endometrium in postmenopausal women]. | journal=Ginekol Pol | year= 2008 | volume= 79 | issue= 11 | pages= 758-61 | pmid=19140498 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19140498  }} </ref>   
|Lack of longterm evidence on efficacy
|
Increases recurrence risk of breast cancer in patients with history of breast cancer
* Lack of long term evidence on efficacy
 
* Increases recurrence risk of [[breast cancer]] in patients with history of [[breast cancer]]
Vaginal spotting and bleeding<ref name="pmid27733017">{{cite journal| author=Formoso G, Perrone E, Maltoni S, Balduzzi S, Wilkinson J, Basevi V et al.| title=Short-term and long-term effects of tibolone in postmenopausal women. | journal=Cochrane Database Syst Rev | year= 2016 | volume= 10 | issue=  | pages= CD008536 | pmid=27733017 | doi=10.1002/14651858.CD008536.pub3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27733017  }}</ref>
* Vaginal spotting and bleeding<ref name="pmid27733017">{{cite journal| author=Formoso G, Perrone E, Maltoni S, Balduzzi S, Wilkinson J, Basevi V et al.| title=Short-term and long-term effects of tibolone in postmenopausal women. | journal=Cochrane Database Syst Rev | year= 2016 | volume= 10 | issue=  | pages= CD008536 | pmid=27733017 | doi=10.1002/14651858.CD008536.pub3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27733017  }}</ref>
|-
|-
|Oxytocin
|[[Oxytocin]]
|Oxytocin gel improves vaginal secretions and epithelial thickness and pH<ref name="Al-SaqiUvnas-Moberg2015">{{cite journal|last1=Al-Saqi|first1=S. H.|last2=Uvnas-Moberg|first2=K.|last3=Jonasson|first3=A. F.|title=Intravaginally applied oxytocin improves post-menopausal vaginal atrophy|journal=Post Reproductive Health|volume=21|issue=3|year=2015|pages=88–97|issn=2053-3691|doi=10.1177/2053369115577328}}</ref><ref name="pmid268836892">{{cite journal| author=Al-Saqi SH, Jonasson AF, Naessén T, Uvnäs-Moberg K| title=Oxytocin improves cytological and histological profiles of vaginal atrophy in postmenopausal women. | journal=Post Reprod Health | year= 2016 | volume= 22 | issue= 1 | pages= 25-33 | pmid=26883689 | doi=10.1177/2053369116629042 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26883689  }}</ref>
|
|No endometrial hyperplasia
* [[Oxytocin]] gel improves vaginal secretions and epithelial thickness and pH<ref name="Al-SaqiUvnas-Moberg2015">{{cite journal|last1=Al-Saqi|first1=S. H.|last2=Uvnas-Moberg|first2=K.|last3=Jonasson|first3=A. F.|title=Intravaginally applied oxytocin improves post-menopausal vaginal atrophy|journal=Post Reproductive Health|volume=21|issue=3|year=2015|pages=88–97|issn=2053-3691|doi=10.1177/2053369115577328}}</ref><ref name="pmid268836892">{{cite journal| author=Al-Saqi SH, Jonasson AF, Naessén T, Uvnäs-Moberg K| title=Oxytocin improves cytological and histological profiles of vaginal atrophy in postmenopausal women. | journal=Post Reprod Health | year= 2016 | volume= 22 | issue= 1 | pages= 25-33 | pmid=26883689 | doi=10.1177/2053369116629042 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26883689  }}</ref>
|No longterm evidence<ref name="pmid22120944">{{cite journal| author=Jonasson AF, Edwall L, Uvnäs-Moberg K| title=Topical oxytocin reverses vaginal atrophy in postmenopausal women: a double-blind randomized pilot study. | journal=Menopause Int | year= 2011 | volume= 17 | issue= 4 | pages= 120-5 | pmid=22120944 | doi=10.1258/mi.2011.011030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22120944  }}</ref>
|
* No [[endometrial hyperplasia]]
|
* No long term evidence<ref name="pmid22120944">{{cite journal| author=Jonasson AF, Edwall L, Uvnäs-Moberg K| title=Topical oxytocin reverses vaginal atrophy in postmenopausal women: a double-blind randomized pilot study. | journal=Menopause Int | year= 2011 | volume= 17 | issue= 4 | pages= 120-5 | pmid=22120944 | doi=10.1258/mi.2011.011030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22120944  }}</ref>
|-
|-
|Intravaginal dehydroepiandrosterone
|Intravaginal [[dehydroepiandrosterone]]
|Improves vaginal epithelium thickness and secretions<ref name="pmid26731686">{{cite journal| author=Labrie F, Archer DF, Koltun W, Vachon A, Young D, Frenette L et al.| title=Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. | journal=Menopause | year= 2016 | volume= 23 | issue= 3 | pages= 243-56 | pmid=26731686 | doi=10.1097/GME.0000000000000571 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26731686  }} </ref><ref name="pmid25201455">{{cite journal| author=Archer DF| title=Dehydroepiandrosterone intra vaginal administration for the management of postmenopausal vulvovaginal atrophy. | journal=J Steroid Biochem Mol Biol | year= 2015 | volume= 145 | issue=  | pages= 139-43 | pmid=25201455 | doi=10.1016/j.jsbmb.2014.09.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25201455  }}</ref>
|
|None
* Improves vaginal epithelium thickness and secretions<ref name="pmid26731686">{{cite journal| author=Labrie F, Archer DF, Koltun W, Vachon A, Young D, Frenette L et al.| title=Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. | journal=Menopause | year= 2016 | volume= 23 | issue= 3 | pages= 243-56 | pmid=26731686 | doi=10.1097/GME.0000000000000571 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26731686  }} </ref><ref name="pmid25201455">{{cite journal| author=Archer DF| title=Dehydroepiandrosterone intra vaginal administration for the management of postmenopausal vulvovaginal atrophy. | journal=J Steroid Biochem Mol Biol | year= 2015 | volume= 145 | issue=  | pages= 139-43 | pmid=25201455 | doi=10.1016/j.jsbmb.2014.09.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25201455  }}</ref>
|Lacks longterm studies
|
* None
|
* Lacks long term studies
|-
|-
|Moisturizers and lubricants<ref name="pmid26707589">{{cite journal| author=Edwards D, Panay N| title=Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition? | journal=Climacteric | year= 2016 | volume= 19 | issue= 2 | pages= 151-61 | pmid=26707589 | doi=10.3109/13697137.2015.1124259 | pmc=4819835 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26707589  }} </ref>
|Moisturizers and lubricants<ref name="pmid26707589">{{cite journal| author=Edwards D, Panay N| title=Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition? | journal=Climacteric | year= 2016 | volume= 19 | issue= 2 | pages= 151-61 | pmid=26707589 | doi=10.3109/13697137.2015.1124259 | pmc=4819835 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26707589  }} </ref>
|Polymers adhere to the epithelial and mucin improving vaginal lubrication
|
|Temporary relief for patients with mild symptoms
* Polymers adhere to the epithelial and mucin improving vaginal lubrication
|Doesnt reverse atrophic changes
|
* Temporary relief for patients with mild symptoms
|
* No effect on reversal of  atrophic changes
|}
|}
===Assessment of Response to treatment===
===Assessment of Response to treatment===
*Atrophic vaginitis being a chronic disease continuous therapy is recommended. Response to treatment is assessed by the following:
*Atrophic vaginitis being a chronic disease, continuous therapy is recommended. Response to treatment is assessed by the following:<ref name="pmid27472999">{{cite journal| author=Gandhi J, Chen A, Dagur G, Suh Y, Smith N, Cali B et al.| title=Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. | journal=Am J Obstet Gynecol | year= 2016 | volume= 215 | issue= 6 | pages= 704-711 | pmid=27472999 | doi=10.1016/j.ajog.2016.07.045 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27472999  }} </ref>
**Vaginal Maturation Index(VMI) assessment
**Vaginal Maturation Index(VMI) assessment
**Vaginal pH assessment
**Vaginal [[pH]] assessment


==Prevention==
==Prevention==
===Primary Prevention===
===Primary Prevention===
There are no primary preventive measures for atrophic vaginitis.
There are no primary preventive measures for [[atrophic vaginitis.]]
 
===Secondary Prevention===
===Secondary Prevention===
The following behavioral changes are advised to stop progression of atrophic vaginitis, and also help in maintenance of normal vaginal tissue:<ref>{{cite journal|title=Management of symptomatic vulvovaginal atrophy|journal=Menopause: The Journal of The North American Menopause Society|volume=20|issue=9|year=2013|pages=888–902|issn=1072-3714|doi=10.1097/GME.0b013e3182a122c2}}</ref>
The following behavioral changes are advised to slow down the progression of atrophic vaginitis, and also help in maintenance of normal vaginal tissue:<ref>{{cite journal|title=Management of symptomatic vulvovaginal atrophy|journal=Menopause: The Journal of The North American Menopause Society|volume=20|issue=9|year=2013|pages=888–902|issn=1072-3714|doi=10.1097/GME.0b013e3182a122c2}}</ref>
*Encouraging sexual activity helps in the maintainence of vaginal elasticity and lubrication in response to sexual stimulation.
*Encouraging [[sexual activity]] helps in the maintenance of vaginal elasticity and lubrication in response to sexual stimulation.
*Stress reduction therapy is helpful in patients with non-organic causes of vaginal dryness.
*Stress reduction therapy is helpful in patients with non-organic causes of [[vaginal dryness]].
*Cessation of smoking
*Cessation of [[smoking]]
*Encourage the use of looser undergarments; increases the vascularity and prevents infections.
*Encourage the use of looser undergarments; it increases the vascularity and prevents infections.


==References==
==References==
{{reflist|2}}
{{reflist|2}}


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{{WS}}
{{WS}}


[[Category:Primary care]]
[[Category:Gynecology]]
[[Category:Gynecology]]

Latest revision as of 20:32, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2] Aravind Kuchkuntla, M.B.B.S[3]

Synonyms and keywords: Atrophic vulvovaginitis; vaginal atrophy; urogenital atrophy; genitourinary syndrome of menopause

Overview

Atrophic vaginitis is defined as inflammation of the vaginal epithelium due to atrophy secondary to decreased levels of circulating estrogen. The features of this disease are estimated to be seen in 15% of premenopausal and 50% menopausal women. Patients present with the symptoms of vaginal dryness, itching, irritation, and dyspareunia. Diagnosis of atrophic vaginitis requires subjective assessment of the severity of symptoms to be correlated with the physical examination findings. The prominent physical examination findings include atrophic vaginal or vulvar tissue, pale, smooth and shiny vaginal epithelium with increased friability and inflammation with patchy erythema. The characteristic findings to confirm the diagnosis are: a left shift of the vaginal maturation index on a vaginal smear and a alkaline pH of the vagina. However, other secondary causes such as lichen sclerosus and lichen planus must be ruled before the confirmation of the diagnosis. The therapeutic management is based on the severity of the symptoms: lubricants are the first line of therapy for mild symptoms, in patients unresponsive to lubricants and with moderate to severe symptoms topical or oral estrogen therapy is effective for the management of patients . Majority of the patients have resolution of symptoms but due to the chronic nature of the condition it requires continuous treatment.

Historical Perspective

  • In 1898, Charles B. Penrose described vaginitis in elderly women as senile Vaginitis. The areas of patchy inflammation were treated with 5% silver nitrate solution.[1]
  • In 1940, Jacob described the use of vaginal pH in determination of hypoestrogenic state.[2]
  • In 1947, Racoff gave a description the efficacy and safety of a synthetic estrogen, dienestrol for the treatment of menopausal syndrome and atrophic vaginitis is described.[3]
  • In 1963, topical Dinesterol vaginal cream was used for the treatment of senile vaginitis.[4]
  • In 1967, the relationship between the vaginal maturation index and estrogen therapy was described.[5]
  • In 2013, vulvovaginal atrophy is renamed as genitourinary syndrome of menopause.[6]

Classification

Atrophic vaginitis is classified based on the symptom severity into:[7]

  • Mild: Patients present with symptoms related to sexual activity.
  • Moderate to severe: Patients with persistent symptoms not related to sexual activity.

Pathophysiology

Pathogenesis

The pathogenesis of atrophic vaginitis is due to decreased estrogen levels. Estrogen is a vasoactive hormone, which increases blood flow and maintains vaginal lubrication through fluid transudation from blood vessels.[8] The following are the manifestations of decreased estrogen levels:[8][9][10]

Genetics

There are no genetic factors associated with atrophic vaginitis.

Gross Pathology

Gross pathology findings in atrophic vaginitis include:[11]

  • Vaginal dryness
  • Loss of vaginal rugae
  • Changes in vaginal mucosa: pallor and friability or redness and petechiae of the mucosa

Microscopic Pathology

  • Cytology of the vaginal cells show an increase in the parabasal cells and decreased superficial cells. In situations of low estrogen levels the vaginal epithelium ceases to produce superficial and intermediate squamous cells, leaving only the parabasal and basal cells lining the vaginal wall.[12]

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:[8]

Ovarian Failure Other causes
Menopause Elevated Prolactin during the Postpartum period
Premature Ovarian Failure

Bilateral oophorectomy

Pituitary Adenoma
Chemotherapy and Radiation Medications with anti-estrogenic effect

Epidemiology and Demographics

  • Atrophic vaginitis is often an underdiagnosed condition and exact prevalence estimation is difficult because of the following reasons:
    • Majority of women are embarrassed to discuss their symptoms with doctors and few others think the symptoms associated with atrophic vaginitis as a process of natural aging.[14]
    • Only 25% of patients with symptoms seek medical care.[15]
    • Inadequate relief of symptoms with treatment.[16]
  • The features of atrophic vaginitis are estimated to be seen in 15% of premenopausal women and 40-54% of post-menopausal women.[17]
  • 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).[9]

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:[8]

Screening

There are no screening recommendations for atrophic vaginitis.[18]

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:[9] [8]

The conditions which may need to be differentiated from the atrophic vagintis and presents as vulvar or vaginal pruritus, dryness, discharge and dyspareunia include the following: [19][20][21][22][23]

Disease Findings
Atrophic vaginitis
Trichomoniasis
Bacterial Vaginosis
Candida Vulvovaginitis
Lichen Sclerosus
Lichen Planus
  • Affects pre-menopausal and post menopausal women[25]
  • T-cell mediated inflammatory disease affecting mucosal membranes
  • In erosive form patients present with vulvar pain, dyspareunia and dysuria
  • Non-erosive form presents with pruritus
  • On examination, lesions appear as red plaques or erosions, with overlying white violaceous or reticular plaques( Wickham Striae)
  • Diagnosis confirmed by shave or punch biopsy
Lichen simplex chronicus
  • On examination, the lesion appear as thick, erythematous lichenified skin (epidermal thickening and accentuation of skin markings)
  • Due to long-term rubbing or scratching secondary to conditions such as recurrent yeast infections, contact dermatitis, psychiatric illness[26]
Contact dermatitis
  • It could be allergic or irritant contact dermatitis
  • Presents with redness, swelling, and pruritus[27]
  • Ocassionally blistering and painful bright red swelling can be seen
Vulvar intraepithelial neoplasm
  • Bimodal peak is observed between 40-44 years and above 55 years[28]
  • Red, white, or dark raised or eroded multifocal lesions [29][30]
Vulvar Cancer
Extramammary Paget disease

Natural History, Complications and Prognosis

Natural History

Atrophic vaginitis is a chronic progressive medical problem affecting postmenopausal women and in younger women with low estrogen levels. Women present with vaginal dryness, pruritus, urinary disturbances and dyspareunia.[34]

Prognosis

Atrophic vagnitis is a chronic disease and requires continuous treatment with estrogen or other alternatives. Majority of the patients have significant resolution of the symptoms with treatment, however the symptoms recur once the treatment is stopped.[35]

Complications

Complications of atrophic vaginitis include:[8][36][17]

Diagnosis

History and Symptoms

Symptoms of atrophic vaginitis can be divided into three categories:[8][9][10]

Physical Examination

Physical examination in women with atrophic vaginitis includes a general inspection of the external genitalia, a speculum examination.[10][21]

Laboratory Findings

Assessment of Vaginal Atrophy

  • Vaginal Cytology: It demonstrates a decrease in the superficial squamous cells and an increased parabasal cells.[12]
  • Vaginal Maturation Index(VMI): It represents the percentage of the parabasal, intermediate and superficial squamous cells. It read from left to right as follows, for example if its represented as 0/35/65-it means the smear has 0% parabasal cells, 35% intermediate cells and 65% superficial cells. A shift to the left indicates vaginal atrophy.[38]
  • Vaginal Maturation Value (VMV): It is calculated using a formula: 0 * %parabasal cells + 0.5 * %intermediate cells + 1.0 * superficial cells divided by 2.
    • A lower VMV indicates a low number of superficial cells indicating hypoestrogenic state.[39]
  • Vaginal pH : Normal vaginal pH is acidic and is maintained by the lactobacillus flora by the breakdown of glucose (from the vaginal epithelial cell glycogen-the level of which is based on the estrogen) to lactic acid.
    • In lower estrogen states, the vaginal pH is typically greater then 5; higher than normal due to lower levels of glycogen in the epithelial cells. It is a useful and inexpensive test in the absence of bacterial vaginosis to indicate vaginal atrophy.[40]
  • Wet mount of vaginal smear : Demonstrates the paucity of lactobacillus.
  • FSH Level: Estimation of FSH is not neccessary for the diagnosis of hypoestrogenic state as alkaline pH of vaginal secretions is equally sensitive.[41]

Ultrasound

An ultrasound of the uterus may demonstrate thinning of the endometrium lining to 4-5mm.[8]

Treatment

Medical Therapy

Atrophic vaginitis is a chronic condition requiring continuous treatment. The choice of therapy is based on the severity of the symptoms and associated factors such as history of hormone dependent cancer. [42][43]

Treatment Modality Improvement in symptoms Advantages Limitations
Topical Estrogen[46][9][47]

(Creams and Estradiol releasing vaginal rings)

  • No systemic absorption
  • 80 to 90% patients have symptomatic improvement[50]
  • Creams can be messy to use
  • Rings are expelled in patients with cystocele and rectocele
  • Side effects include vaginal secretion, vaginal spotting, and genital pruritus
Oral Estrogen Therapy

In addition to the changes with topical estrogen other actions include:

Selective estrogen receptor modulator

Ospemifene[51]

Laser Therapy
  • Improvement of symptoms sustained at 12 weeks after therapy
  • Improved sexual activity[55]
Lack of long term evidence on efficacy and safety[56]
  • Common adverse effect is hot flashes
  • Contraindicated in patients with DVT
Tibolone

Synthetic steriod

  • Improves VMI, sexual desire with the androgenic activity[57]
  • Improvement in urinary symptoms
  • Lack of long term evidence on efficacy
  • Increases recurrence risk of breast cancer in patients with history of breast cancer
  • Vaginal spotting and bleeding[59]
Oxytocin
  • Oxytocin gel improves vaginal secretions and epithelial thickness and pH[60][61]
  • No long term evidence[62]
Intravaginal dehydroepiandrosterone
  • Improves vaginal epithelium thickness and secretions[63][64]
  • None
  • Lacks long term studies
Moisturizers and lubricants[65]
  • Polymers adhere to the epithelial and mucin improving vaginal lubrication
  • Temporary relief for patients with mild symptoms
  • No effect on reversal of atrophic changes

Assessment of Response to treatment

  • Atrophic vaginitis being a chronic disease, continuous therapy is recommended. Response to treatment is assessed by the following:[8]
    • Vaginal Maturation Index(VMI) assessment
    • Vaginal pH assessment

Prevention

Primary Prevention

There are no primary preventive measures for atrophic vaginitis.

Secondary Prevention

The following behavioral changes are advised to slow down the progression of atrophic vaginitis, and also help in maintenance of normal vaginal tissue:[66]

  • Encouraging sexual activity helps in the maintenance of vaginal elasticity and lubrication in response to sexual stimulation.
  • Stress reduction therapy is helpful in patients with non-organic causes of vaginal dryness.
  • Cessation of smoking
  • Encourage the use of looser undergarments; it increases the vascularity and prevents infections.

References

  1. "A Text-book of Diseases of Women - Charles Bingham Penrose - Google Books".
  2. Beilly, Jacob S. (1940). "DETERMINATION OF PH OF VAGINAL SECRETION AS AN INDEX OF OVARIAN ACTIVITY IN HYPOOVARIAN STATES". Endocrinology. 26 (6): 959–964. doi:10.1210/endo-26-6-959. ISSN 0013-7227.
  3. Rakoff, A. E.; Paschkis, K. E.; Cantarow, A. (1947). "A CLINICAL EVALUATION OF DIENESTROL, A SYNTHETIC ESTROGEN1". The Journal of Clinical Endocrinology & Metabolism. 7 (10): 688–700. doi:10.1210/jcem-7-10-688. ISSN 0021-972X.
  4. Falk, Henry C.; Hassid, Roger (1963). "ATROPHIC OR SENILE VAGINITIS: TREATMENT WITH DIENESTROL CREAM". Journal of the American Geriatrics Society. 11 (12): 1152–1157. doi:10.1111/j.1532-5415.1963.tb02686.x. ISSN 0002-8614.
  5. "Limited Relationship of Maturation Index to Estrogen Therapy... : Obstetrics & Gynecology".
  6. Portman DJ, Gass ML, Vulvovaginal Atrophy Terminology Consensus Conference Panel (2014). "Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society". Maturitas. 79 (3): 349–54. doi:10.1016/j.maturitas.2014.07.013. PMID 25179577.
  7. Domoney, Claudine (2014). "Treatment of vaginal atrophy". Women's Health. 10 (2): 191–200. doi:10.2217/whe.14.9. ISSN 1745-5057.
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  35. "Management of symptomatic vulvovaginal atrophy". Menopause: The Journal of The North American Menopause Society. 20 (9): 888–902. 2013. doi:10.1097/GME.0b013e3182a122c2. ISSN 1072-3714.
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  42. "Management of symptomatic vulvovaginal atrophy". Menopause: The Journal of The North American Menopause Society. 20 (9): 888–902. 2013. doi:10.1097/GME.0b013e3182a122c2. ISSN 1072-3714.
  43. Stuenkel CA, Davis SR, Gompel A, Lumsden MA, Murad MH, Pinkerton JV; et al. (2015). "Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline". J Clin Endocrinol Metab. 100 (11): 3975–4011. doi:10.1210/jc.2015-2236. PMID 26444994.
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  45. Domoney C (2014). "Treatment of vaginal atrophy". Womens Health (Lond). 10 (2): 191–200. doi:10.2217/whe.14.9. PMID 24601810.
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