Vaginal Atrophy: The 21st Century Health Issue Affecting Quality of Life

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Special Populations

Vaginal atrophy can also be associated with abruptly induced menopause and result in significant symptoms, sexual dysfunction and distress, and poor quality of life. Cancer treatments (surgically induced menopause, chemotherapy induced ovarian failure, radiation damage to ovaries, or maintenance endocrine therapies) can all cause ovarian dysfunction and lead to vaginal atrophy. For example, patients with breast cancer treated with an aromatase inhibitor have been found to experience significant vaginal dryness and painful coitus.^[11]

Cancer

The NAM position statement also addresses women with past or current treatment for a malignancy in whom vaginal atrophy develops. Recommendations include that those without hormonally sensitive tumors should not be treated differently than routinely managed postmenopausal patients.

However, patients with hormonally sensitive carcinoma (common in breast and endometrial malignancies) require individualized treatment, based on extensive discussion between the patient and her oncological management team. The safety of local estrogen use in breast or endometrial cancer survivors or those with a strong family history of breast cancer has not been adequately studied in long-term, randomized, placebo-controlled trials. To date, no vaginal estrogen product has been approved by the Food and Drug Administration for use in patients with a hormonally sensitive malignancy.

Presently there is no established protocol for use of local estrogen in breast cancer survivors with vaginal atrophy. Of note, in a cohort study of almost 1500 previously treated patients with breast cancer, no statistically significant difference in disease free interval was found between a subgroup of women using vaginal estrogen and those not using estrogen.^[12]

Several sexual medicine programs are investigating use of individually tailored treatment of vaginal atrophy to determine the lowest dose of local estrogen significantly associated with effective physiological results. Women with hormonally sensitive cancer, other malignancies, and women without cancer are participating in these investigations. Data from these studies have not been published.

Use of local estrogen in patients with endometrial cancer remains controversial; many clinicians opt for no estrogen therapy while others consider use permissible. Tumor stage, grade depth of invasion, and time since cancer treatment may factor into the decision process.

A related concern is that local estrogen could possibly effect endometrial proliferation, which in turn could increase the risk of endometrial cancer. However, a study of low dose vaginal ring and vaginal tablet users that assessed endometrial thickness via ultrasound found no significant changes in the endometrium.^[13]

Additionally, Nachtigall reported results of use of low-dose estrogen therapy evaluated via endometrial biopsy that showed no significant local or first-pass absorption into the uterus.^[14] Based on these data, she contended that treatment with low-dose estrogen is safe in early stage endometrial cancer survivors who have undergone hysterectomy and were appropriately staged and effectively treated.

Appropriate discussion concerning the lack of long-term safety data, coupled with meticulous, well-documented informed consent specific to risks and benefits should take place prior to prescribing local estrogen for any patient with a history of a hormone-sensitive malignancy.

Endometriosis or Leiomyomata

Young women with endometriosis or large leiomyomata treated with gonadotropin-releasing hormone agonists or antagonists that induce a hypoestrogenic state may suffer from periodic vaginal atrophy and should be evaluated and treated accordingly. Use of minimally absorbed vaginal estrogen products is warranted because treatment has a positive effect on atrophy and does not reactivate underlying endometriosis.

Lactation

Women breastfeeding exclusively may experience lactation-induced amenorrhea, diminished estradiol levels, and elevated prolactin and oxytocin levels. These changes can cause vaginal dryness and atrophy, accompanied by lowered libido and painful, unsatisfying intercourse. Because many healthcare providers attribute decreased sexual interest during the postpartum period to other causes (fatigue/sleeplessness, exhaustion of motherhood, changing sexual dynamics of the couple, stress and recovery from delivery), lactation-induced vaginal atrophy often is misdiagnosed or remains undiagnosed.

Other special causes of vaginal atrophy should always be considered, so that these women can be identified and effectively managed. Additional plausible causes of vaginal and vulvar atrophy include allergy suffers with chronic antihistamine use those being treated with parasympathomimetic or tricyclic antidepressant medications.^[15] Women using an oral contraceptive may also experience dryness. Women with Sjorgen's syndrome may experience lack of vaginal lubrication despite adequate estrogen levels. Atrophic vaginitis also can develop in anorexia nervosa, bulimia, or in those undergoing infertility treatments.

Clinical Pearls

Vaginal atrophy is often neglected by the even the etude healthcare professional. Additionally, patients are frequently hesitant to discuss possibly embarrassing and uncomfortable problems, may dismiss their symptoms as natural processes of aging or chronic medical disease, or be unaware that effective treatments are available. It is imperative for healthcare providers to initiate directive questioning and to engage patients in frank discussion concerning sexuality and urogenital symptoms. Clinicians cannot treat a problem if they do not know that one exists.

Creating a comfortable, safe, warm environment where the patient can discuss concerns is paramount. Use of open ended questions and directed, follow up queries facilitates comprehension of medical issues. Allowing appropriate time for the questions and active listening can also elicit optimal responses from patients.

Clinicians that are uncomfortable with discussing or treating sexually-related complaints should develop community resources for referral. Continuing education focused on sexual history-taking or approaches to sexual dysfunction may also be helpful.

Conclusion

Women are living longer, healthier, productive lives, and are now expected to live about one third of their lives after menopause. Vaginal atrophy and related symptoms associated with natural or induced menopause, cancer treatment, lactation, medications, or chronic conditions warrant prompt identification, correct diagnosis, and optimal treatment. A variety of safe, effective treatment options are available. Careful assessment of the needs of individual needs and preference may facilitate successful treatment outcome. Sexuality can be enhanced, urologic functioning significantly improved, and quality of life positively affected when vaginal atrophy is recognized and treated.

Supported by an independent educational grant from NovoNordisk