Practical Aspects in the Management of Vaginal Atrophy and Sexual Dysfunction in Perimenopausal and Postmenopausal Women

Abstract

Introduction The decline in circulating estrogen levels in peri- and postmenopause has a wide range of physiological effects, including atrophy of tissues in the urogenital tract. Vaginal atrophy is an important contributor to postmenopausal sexual dysfunction. Aim To provide a framework for clinical evaluation and clinical management of sexual dysfunction secondary to vaginal atrophy. Method Conduct a brief overview of literature on evaluation and treatment of vaginal atrophy, augmented with the authors’ clinical observations and experience. Results Estrogen decline disrupts many physiological responses characteristic of sexual arousal, including smooth muscle relaxation, vasocongestion, and vaginal lubrication; genital tissues depend on continued estrogen and androgen stimulation for normal function. An upward shift in vaginal pH as the result of vaginal atrophy alters the normal vaginal flora. Reduced lubrication capability and reduced tissue elasticity, in addition to shortening and narrowing of the vaginal vault, can lead to painful and/or unpleasant intercourse. At the same time, diminished sensory response may reduce orgasmic intensity. Other contributors to peri- and postmenopausal sexual dysfunction include reduced androgen levels, aging of multiple body systems, and side-effects of medications. Workup of sexual health problems starts by taking a comprehensive sexual, medical, and psychosocial history, followed by complete physical examination and laboratory evaluation. Clinical management includes measures to preserve and enhance overall health, adjustment of medication regimes to reduce or avoid side-effects, and topical or systemic hormone supplementation with estrogens and/or androgens. Conclusions No single therapeutic approach is appropriate for every woman with peri- or postmenopausal sexual dysfunction; instead, treatment should be based on a comprehensive evaluation and consideration of medical and psychosocial contributors to the individual's dysfunction. Further research is required to establish optimal regimens of hormonal and nonhormonal agents, including dosages/dosage forms and duration of treatment, for specific subtypes of sexual dysfunction.

Challenges in the Gynecologic Care of Premenopausal Women With Breast Cancer

“…112,113 Management options are listed in Table 3. Nonestrogenic treatments such as nonhormonal lubricants and vaginal moisturizers should be first-line therapy for women with a history of breast cancer because they have been shown to improve blood flow to vulvovaginal tissue and improve dryness.…”

Recognizing and Treating Urogenital Atrophy in Postmenopausal Women

“…22 Estrogen deficiency may also decrease vaginal function and interfere with physiological responses associated with sexual arousal, including smooth muscle relaxation, vasocongestion, and vaginal lubrication. 3 For example, vaginal blood flow and vaginal secretions decrease, and lubrication after sexual stimulation is decreased and delayed. 22 Reduced vestibular sensation and diminished perception of vibratory, hot, and cold stimuli also may occur.…”

“…3 Estrogen receptors in the genitourinary system are found not only in the vagina and vulva but also in the urethra and neck of the bladder. 24,25 A recent study in which investigators performed RNA profiling on vaginal biopsies of postmenopausal women with vaginal atrophy after treatment with estrogen found that more than 3000 genes are regulated by estrogen, including those involved in regulating cell growth and proliferation and defense against pathogens.…”

“…Urogenital atrophy, sexual dysfunction, and urinary symptoms have been reported to cause significant emotional distress and reduced quality of life in women. [2][3][4] Urogenital atrophy associated with estrogen decline can lead to vulvovaginal symptoms and sexual dysfunction. Common vulvovaginal symptoms, which can range in intensity from annoying to debilitating, include dyspareunia and vaginal discomfort, dryness, itching, and burning.…”

“…As a result, vaginal atrophy can be a significant problem in sexually active women who may find sexual activity uncomfortable because of their symptoms. 3 Urogenital atrophy associated with estrogen decline can also lead to lower urinary tract dysfunction and urinary symptoms, such as increased frequency, urgency, dysuria, and recurrent urinary tract infections (UTIs). 1,8 These symptoms can be troubling and can prompt women to make lifestyle changes, such as restricting activity outside the home, using sanitary protection, and altering fluid intake.…”