A 60-year-old woman with vaginal dryness and irritation is seen to follow up on an inflammatory Pap smear. She denies discharge, odor, douching, and sexually transmitted disease (STD) exposure. She does admit to some postcoital bleeding. Her cervix has atrophic changes and an endocervical polyp (Figure 83-1). The polyp was removed easily with a ring forceps, and no dysplasia was found on pathology.
Colposcopic photograph (scanning objective with 10× eyepiece) demonstrating atrophic vaginitis. Note thinned white epithelium, friable epithelium with bleeding, and a cervical polyp. (Reproduced with permission from E.J. Mayeaux, Jr., MD.)
Vaginal atrophy caused by estrogen deficiency is common and usually is asymptomatic. It can, however, be the etiology of such problems as recurrent urinary tract infections, vaginal dryness, dyspareunia, postcoital spotting, or recurrent bacterial vaginosis.
Vaginal atrophy, vulvovaginal atrophy, urogenital atrophy, senile vaginitis.
The average age of menopause is 51 years in the United States.
Approximately 5% of women experience menopause after age 55 years (late menopause), and another 5% experience the transition between the ages of 40 and 45 years (early menopause). This means that in the United States, most women will live a significant portion of their lives during menopause. In addition, women who undergo surgical menopause will experience these symptoms at a typically younger age. To a lesser extent, women who undergo ovarian suppression without estrogen supplementation (progestin-only contraceptives) are susceptible to atrophic changes in their lower genital tract.
Vaginal dryness occurs in approximately 3% of women of reproductive age, 4% to 21% of women in the menopausal transition, and 47% of women 3 years postmenopause.1 Internationally, 39% of women experience menopause-related vaginal discomfort.2
ETIOLOGY AND PATHOPHYSIOLOGY
Prior to menopause, estrogen stimulates vaginal epithelial cells to produce glycogen, which is then released into the vagina and converted to glucose. This supports vaginal flora that includes Lactobacillus, which converts it to lactic acid and decreases the vaginal pH to the 3.5–4.5 typically seen in vaginal secretions.3 After menopause, circulating estrogen levels dramatically decrease to a level at least one-sixth their premenopausal levels.4 Changes that occur in the vaginal and cervical epithelium include proliferation of connective tissue, loss of elastin, thinning of the epithelium (Figure 83-2), and hyalinization of collagen.
The age of onset of menopause appears to be predominantly genetic but seems to be lowered by smoking and malnutrition and increased by body mass index (BMI) and increasing parity.5
A long-term decrease in estrogen is generally necessary before symptoms become apparent. Genital symptoms include decreased vaginal lubrication, dryness, burning, dyspareunia, leukorrhea, itching, and yellow malodorous discharge.
Urinary symptoms, such as frequency, hematuria, urinary tract infection, dysuria, ...