Clinical signs of urogenital atrophy
Estrogen is important to preserve epithelial thickness and the vaginal
rugae, which are lost due to collagen breakdown in association with a
postmenopausal estrogen deficient hormonal milieu. Estrogen is also
responsible for the pink colour and the secretions seen in a normal
healthy vaginal mucosa. In addition to the typical pallor, mucosal
thinning and a reduction in vaginal secretions, there are other possible
clinical signs of urogenital atrophy. There may be discharge and odour
due to an overgrowth of vaginal commensal organisms and an increase in
vaginal pH (>5).
Other potential changes include an alteration in pubic hair, a reduction
in the fat content of the labia majora, the labia minora may undergo
resorption and fusion, with the clitoris becoming either lost from view
or constantly exposed due to loss of mobility of the clitoral hood and
the urethra can become more prominent. The introitus may become
deficient, with tissue splitting in the posterior fourchette. The vagina
can be shortened with possible obliteration of the vaginal vault and
prolapse (cystocele or rectocele).
Clinical examination is of vital importance in women presenting with
possible urogenital atrophy, as many other urogenital conditions can
also cause similar symptoms. The differential diagnosis includes eczema,
psoriasis, lichen sclerosis et atrophicus, lichen planus, vulval
intraepithelial neoplasia and cancer.
The International Society for the Study of Women’s Sexual Health and the
North American Menopause Society agreed in 2014, that a comprehensive
diagnostic method to facilitate and standardise the physical examination
was needed12. However, to date there has been no
agreement on a validated standardised means of assessment for use in
daily clinical practice.
Treatment options include vaginal lubricants and moisturisers to reduce
symptoms of dryness and pain associated with sexual activity. Systemic
estrogen in hormone replacement therapy does not always prevent a
deterioration in urogenital tissue quality and the best recognised
treatment is vaginally delivered estrogen either as estradiol or the
weaker estrogen estriol with various product choices. Newer treatment
options include DHEA delivered vaginally and a selective estrogen
receptor modulator, ospemifene which is taken orally. Both DHEA and
ospemifene are used daily. Laser therapy, both CO2 and erbium yag laser
are still considered as a research treatment modality in the UK with a
call for randomised controlled trials using sham laser as a comparator.
In summary, urogenital atrophy is evidently a very common condition,
which places a huge burden on many women. In our opinion, the current
evidence indicates the urgent need to develop a comprehensive and robust
diagnostic method that is patient centric and equally suitable for use
in both clinical and research settings. This will not only facilitate
early diagnosis and initiation of the available treatment options but
will also support research in to developing new treatment strategies
that will benefit millions of women suffering silently from this
distressing condition.
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