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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¹ Shaikh Zinnat Ara Nasreen, Safinaz Shahreen, Saleheen Huq, Sabereen Huq, Genito Urinary Syndrome of Menopause (GSM) or Vulvo-vaginal Atrophy (VVA) an Unspoken Sorrow, American Journal of Internal Medicine . Vol. 7, No. 6, 2019, pp. 154-162

² Domoney C, Currie H, Panay N, Maamari R, Nappi RE. The CLOSER survey: impact of postmenopausal vaginal discomfort on women and male partners in the UK. Menopause International . 2013;19(2):69-76

³ Nappi RE, Martini E, Cucinella L, Martella S, Tiranini L, Inzoli A, et al. Addressing Vulvovaginal Atrophy (VVA)/Genitourinary Syndrome of Menopause (GSM) for Healthy Aging in Women. Frontiers in Endocrinology, 2019, Volume 10, 1664-2392

⁴ Briggs P, Hapangama DK. Urogenital atrophy: The ‘unknown factors’ challenging current practice. Post Reproductive Health . March 2021. doi:10.1177/2053369121997673

⁵ Nappi RE, Palacios S, Panay N, Particco M, Krychman ML. Vulvar and vaginal atrophy in four European countries: evidence from the European REVIVE Survey. Climacteric: The Journal Of The International Menopause Society. 2016;19(2):188-97

⁶ Nappi RE, de Melo NR, Martino M, Celis-González C, Villaseca P, Röhrich S, et al. Vaginal Health: Insights, Views & Attitudes (VIVA-LATAM): results from a survey in Latin America. 2018

⁷ Domoney C, Currie H, Panay N, Maamari R, Nappi RE. The CLOSER survey: impact of postmenopausal vaginal discomfort on women and male partners in the UK. Menopause International . 2013;19(2):69-76

⁸ Palma F, Volpe A, Villa P, Cagnacci A, Writing Grp AS. Vaginal atrophy of women in postmenopause. Results from a multicentric observational study: The AGATA study. 2016. p. 40-4

⁹ Palma F, Xholli A, Cagnacci A. Management of vaginal atrophy: a real mess. Results from the AGATA study. Gynecological Endocrinology: The Official Journal Of The International Society Of Gynecological Endocrinology. 2017;33(9):702-7

¹⁰ Chang OH, Paraiso MF. Revitalising Research in Genitourinary Syndrome of Menopause. American Journal of Obstetrics and Gynaecology. 2019:246-8

¹¹ Panay N, Briggs P, Kovacs G. Managing the menopause : 2^nd Edition. Cambridge University Press. 2020. ISBN 978-1-10879875.4

¹² Portman DJ, Gass MLS. 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 of Sexual Medicine. 2014 (12):2865.