Vaginal atrophy
| Classification according to ICD-10 | |
|---|---|
| N95.2 | atrophic colpitis in postmenopause |
| N90.5 | Atrophy of the vulva |
| ICD-10 online (WHO version 2019) | |
As vaginal atrophy (expressed cautiously vaginal aging) is defined as the degeneration of the wall of the vagina ( collagen fibers , vaginal epithelium ) and the Epithelfalten to a thin and smooth surface. The cause is mostly the natural lack of estrogen after the last menstrual period ( menopause ), which in all women after the menopause (post menopause) leads to vulvovaginal atrophy with typical symptoms such as vaginal dryness (up to 80%) and in almost 50% of them pain Sexual intercourse ( dyspareunia ). Because the symptoms are caused by the natural decline in hormone levels during menopause, it can potentially affect any woman at this stage of life.
anatomy
The vaginal epithelium is a gland-free, cutaneous mucous membrane made up of four layers. The top one consists of multilayered, uncornified squamous epithelium. The intercellular layer is formed by the interstitial or prickly cells. The base consists of the parabasal and basal cells, whereby the basal cells are in direct contact with the connective tissue via the basement membrane.
Symptoms
Vaginal atrophy does not necessarily have to cause problems. When symptoms occur, these are usually vaginal dryness, frequent inflammation, burning, itching, redness and easy vaginal bleeding. These complaints are physically and emotionally stressful for the women concerned. Up to two-thirds of them are affected by the symptoms to such an extent that they avoid intimacy altogether and around 45% of them find sex less satisfying.
causes
The vaginal epithelium consists of a multi-layered, uncornified squamous epithelium, the thickness of which is strongly dependent on the hormone level. Estrogen causes cells to build up and increases glycogen storage in the cells, while progesterone counteracts cell build-up (→ vaginal cytology ). Estrogens also play an important role in the formation of collagen fibers, which are essential for the elasticity of the connective tissue of the vaginal wall. The glycogen , a carbohydrate that is made up of glucose, has an important function as it serves the bacteria ( Döderlein bacteria ) naturally resident in the vaginal flora as the basis for lactic acid production, which ultimately determines the acidic environment of the vagina ( pH value approx. 4.0). The acidic environment makes it difficult for dangerous (pathogenic) germs to settle there.
Diagnosis
At the beginning of the diagnosis there should always be a detailed patient survey ( anamnesis ) with a precise description of the symptoms in order to differentiate vaginal atrophy from diseases with similar symptoms. A gynecological examination using a speculum and / or colposcope reveals a thin vaginal wall, which can be associated with punctiform ( petechiae ) and large-scale bleeding ( ecchymosis ). Fine plexuses of veins often shimmer through the thin skin of the vagina. The pH value can be checked using indicator strips , which is in the weakly acidic to neutral range in the case of vaginal atrophy. Another clinical sign of vaginal atrophy is the change in the vaginal maturation index, which provides information about the ratio of the surface cells to the deeper cells and thus shows the local hormonal status.
The vaginal epithelium is subject to hormonal influences and shows changes in the course of the menstrual cycle in sexually mature women . The layer thickness also increases significantly during pregnancy in order to create protection for the birth phase. The cells in the vaginal epithelium are arranged relatively loosely and thus allow lymphocytes and tissue fluid to pass into the vagina. Since the squamous epithelium of the vagina does not contain any glands, the “vaginal secretion” consists only of flaked cells, secretion from the uterus and the moisture that escapes from the cells of the vaginal wall.
If the natural estrogen level decreases with the menopause, the layer thickness of the vaginal wall also decreases. In connection with this, the resilience of the vaginal wall decreases and its sensitivity increases. The amount of vaginal secretion decreases, which consequently accelerates the increase in vulnerability. The vagina becomes increasingly dry (lubrication disorder) and therefore more sensitive to pain, infections, bleeding, itching and burning.
therapy
Despite the frequency of vaginal atrophy, many affected women lack knowledge of the causes of this problem. Almost two thirds do not know that their vaginal symptoms can be treated. Since other menopausal symptoms such as hot flashes, mood swings, etc. are associated with the natural decline in hormone levels, oestrogens (estradiol, estriol and promestrine) often come systemically in the form of tablets, skin patches , according to the guideline recommendation of the Working Group of the Scientific Medical Societies and gels are used to relieve the hormone deficiency and thus treat the underlying problems. However, there is a risk of undesirable effects, especially with long-term use, which is why this treatment is rejected by many women. Estrogens can also be administered locally in the form of vaginal tablets, suppositories and creams, which show little or no systemic effects. Intensive short-term therapy with vaginal ovules or cream is usually used, followed by long-term therapy with extended therapy intervals. The use of hormones is contraindicated, for example after breast cancer. Then moisturizers and lubricants such as hyaluronic acid , glycerol or hydroxyethyl cellulose are used, but these are only a mechanical aid and do not treat the cause of the problem. That is why they must be used regularly and over the long term. Lactobacilli and lactic acid in conjunction with glycogen are also used to support the vaginal environment. An orally applicable active ingredient ospemifene ( SERM ), which has been approved in the USA since 2013, has not been available in Germany since 2017.
Urogenital menopausal syndrome
The term urogenital menopausal syndrome was created in 2014 in an international consensus conference of the North American menopause society as Genitourinary Syndrome of Menopause (GMS), because the commonly used term vulvovaginal atrophy does not adequately describe the variety of symptoms associated with it.
Individual evidence
- ↑ a b Vulvovaginal Atrophy / Genital Menopausal Syndrome Gesundheits-lexikon.com, DocMedicus Verlag, accessed on September 28, 2019
- ↑ a b Nappi RE et al. The CLOSER survey: Impact of postmenopausal vaginal discomfort on relationships between women and their partners in Northern and Southern Europe. Maturitas 2013 Aug; 75 (4): 373-9
- ↑ Nappi RE et al. Vaginal Health: Insights, Views & Attitudes (VIVA) - results from an international survey, Climacteric 2012; 15 (1): 36-44
- ↑ S3 guideline of the AWMF (Working Group of Scientific Medical Societies) 015/062 (currently in revision) Hormone therapy in the peri- and postmenopause (HT)
- ↑ Benefit assessment procedure for the active ingredient ospemifene g-ba.de on October 20, 2016 p. 5, accessed on September 28, 2019