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Postmenopausal vaginal atrophy

Postmenopausal vaginal atrophy. Presentation by the International Menopause Society for World Menopause Day October 18th, 2010. Urogenital atrophy. Estrogen receptors present in: Vagina Urethra Bladder trigone Pelvic floor.

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Postmenopausal vaginal atrophy

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  1. Postmenopausal vaginal atrophy Presentation by the International Menopause Society for World Menopause Day October 18th, 2010

  2. Urogenital atrophy Estrogen receptors present in: • Vagina • Urethra • Bladder trigone • Pelvic floor

  3. Döderlein's lactobacilli convert glycogenfrom sloughed vaginal cells Glycogen formation Mucus layer Vaginal pH (3.5-4.5) Lactic acid Protects from:StreptococcusStaphylococcusColiformDiphtheroid infections Estrogen Maintains thickness of squamous vaginal epithelium, rugae, pink color, and moisture Proliferation of connective tissueFragmentation of elastinHyalanization of collagen

  4. Postmenopausal changesin the vaginal epithelium PREMENOPAUSAL POSTMENOPAUSAL Erectile tissue Folds or rugae Loss of folds Muscular coat Loss of inner lining and glandular function Inner lining contains large amount glycogen Samsioe G. A profile of the Menopause, 1995:49 (Figure 6.4)

  5. Vaginal histology H & E, magnification  10 Premenopause Well-estrogenized epithelium, multi-layered with good blood supply; superficial cells rich in glycogen Postmenopause Estrogen-deficiency atrophy with marked thinning of the epithelium, reduced blood supply and loss of glycogen

  6. Vaginal wall smearunder the microscope Normal: • Superficial cells predominate • Low nuclear/cytoplasmic ratio • Pyknotic nuclei Atrophic: • More parabasal cells • High nuclear/cytoplasmic ratio • Inflammatory exudate

  7. Urinary Urgency Frequency Dysuria Urinary tract infection Incontinence Voiding difficulties Symptoms of urogenital atrophy Vaginal • Dryness • Burning • Pruritus • Dyspareunia • Prolapse

  8. Prevalence of symptoms inwomen treated for breast cancer Menopause Rating Scale; n = 200 Gupta P, et al. Climacteric 2006;9:49–58

  9. Increase in vaginal dryness with menopause 47% 32% 25% 21% 4% 3% Pre-menopause (n = 172) Earlyperimenopause (n = 148) Lateperimenopause (n = 106) Post-menopause1 year (n = 72) Post-menopause2 years (n = 54) Post-menopause3 years (n = 31) Dryness increased significantly in late perimenopause and postmenopause (p <0 .001) Dennerstein L, et al. Obstet Gynecol 2000;96:351–8

  10. Prevalence of superficial dyspareuniaand vulvovaginal atrophy by menopausal age Perimenopause (n = 133) 0–1 year (n = 52) 2–3 years (n = 39) 4 years (n = 67) Atrophy increased significantly with increase in menopausal age (p <0 .001) Adapted from Versi E, et al. Int Urogynecol J 2001;12:107–10

  11. Lower estrogen levels are associatedwith increased prevalence of sexual problems 60 <184 pmol/l (50pg/ml) estradiol >184 pmol/l (50pg/ml) estradiol 50 40 30 % Reporting problems 20 10 0 Vaginal dryness Bothered by problem Dyspareunia (intensity) Pain with penetration Burning n = 93; significance not reported Sarrel PM. J Womens Health Gend Based Med 2000;9:S25–32 Adapted from Sarrel PM. Obstet Gynecol 1990;75(4 Suppl):26–30S

  12. Prevalence of vaginal atrophy • Up to 40% of postmenopausal women experience vaginal atrophy • Only 25% of them seek medical assistance Bachman GA, et al. Am Fam Physician 2000;61:3090–6 Cardozo L, et al. Obstet Gynecol 1998;92:722–7

  13. How to discuss vaginal atrophy with postmenopausal women (1) • Health-care professionals are not asking postmenopausal women about problems such as vaginal dryness • Initiate the discussion about vaginal dryness; your patient may be reluctant • Consider that relationship/sexual issues may present as vaginal discomfort

  14. How to discuss vaginal atrophy with postmenopausal women (2) • Remember that women using systemic estrogen therapy can still develop vaginal symptoms • Be mindful that some urinary symptoms occur concurrently with vaginal atrophy and also respond positively to vaginal estrogen therapy • Encourage women to select a vaginal therapy most comfortable for them

  15. Principles of treatment • Restoration of urogenital physiology • Alleviation of symptoms

  16. Treatment of vaginal atrophy (1) Vaginal moisturizers: • Primarily used to relieve vaginal dryness during intercourse • Do not provide a long-term solution

  17. Treatment of vaginal atrophy (2) Local/topical estrogen: • Logical treatment • Pessaries/vagitories, creams, tablets, or ring Systemic estrogen

  18. Menopausal women sufferingfrom atrophic vaginitis Physician‘s perspective: • Over half of postmenopausal women will have urogenital discomfort associated with estrogen deficiency • Although many women use oral hormone replacement therapy, urogenital symptoms persist Women without systemic HRT Women with systemic HRT Patients suffering from atrophic vaginitis Patients not suffering from atrophic vaginitis 39% 27% 61% 73% Notelovitz M, et al. Obstet Gynecol 2002;99:556–62

  19. Systemic HRT concerns • Breast cancer • Endometrial cancer • Venous thromboembolism • Stroke

  20. How much local estrogen is absorbed into the circulation? • Effects on other tissues • Safety implications • Duration of treatment • Difficulty in measuring estrogens other than 17β-estradiol

  21. Endometrial and vaginal effectsof low-dose estradiol deliveredby vaginal ring or vaginal tablet • Estring (Pharmacia Upjohn), silastic vaginal ring containing 2 mg 17β-estradiol, releasing 8 µg per 24 h over 90 days (n = 126) • Vagifem (Novo Nordisk), mucoadhesive tablet containing 25 µg 17β-estradiol (n = 59) • Mean age = 58 (46–81) years Weisberg E, et al. Climacteric 2005;8:83–92

  22. Estrogen levels duringvaginal therapy Weisberg E, et al. Climacteric 2005;8:83–92

  23. Endometrial thickness during vaginal estrogen therapy Weisberg E, et al. Climacteric 2005;8:83–92

  24. Endometrial and vaginal effectsof low-dose estradiol deliveredby vaginal ring or vaginal tablet Conclusion • Equivalent endometrial safety and efficacy in the relief of the symptoms and signs of urogenital estrogen deficiency were demonstrated for the 12 months’ use of both preparations Weisberg E, et al. Climacteric 2005;8:83–92

  25. Endometrial histology: Vagifem vs. CEE cream (n = 159 treated for 24 weeks) Rioux JE, et al. Menopause 2000;7:156–61

  26. Conclusions and recommendations (1) • Treatment should be started early and before irrevocable atrophic changes have occurred • Treatment needs to be continued to maintain the benefits • All local estrogen preparations are effective and patient preference will usually determine the treatment used

  27. Conclusions and recommendations (2) • Delay in starting local treatment will reduce degree of response • Initial loading dose to stimulate receptors followed by low maintenance dose once or twice per week

  28. Conclusions and recommendations (3) • Additional progestogen is not indicated when appropriate low-dose, local estrogen is used, although long-term data (more than 1 year) are lacking

  29. Conclusions and recommendations (4) • Following gynecological cancer, the use of local estrogen may not be contraindicated; these women should receive appropriate counselling regarding the risks and benefits, taking into account their individual risk factors • Use of local estrogen therapy in women on tamoxifen or aromatase inhibitors needs careful counselling and discussion with the oncology team

  30. Further reading www.imsociety.org IMS Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric 2010;13:509–22

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