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Case History

image A 62-year-old woman consults complaining of vaginal burning, itching and dryness. Sex has been impossible for the past six months and her husband, five years younger than herself, is starting to complain. She was unable to tolerate a speculum examination when taking of a cervical smear was attempted three months ago. She has no hot flushes and has never taken hormone replacement therapy (HRT) and does not want to take systemic oestrogens. Her last period was over ten years ago.

What is the problem?

What are the non-hormonal options?

What are the hormonal options?

How long should she be treated?


What is the problem?

image The problem is called urogenital atrophy and is caused by post-menopausal oestrogen deficiency.

The lower urinary and genital tracts have a common embryological origin. Oestrogen receptors and progesterone receptors are present in the vagina. Oestrogen deficiency after menopause causes atrophic changes. The vaginal mucosa becomes thinner and dry, the epithelium may become inflamed and pH increases, leading to a change in the vaginal flora. Vaginal pH rises to between pH 6.0 and pH 7.5 compared to pre-menopausal levels of pH 3.5 to pH 4.5 which help to prevent colonization with uropathogens. Colonization can lead to vaginal infection. This results in symptoms such as dyspareunia, itching, burning and dryness. The condition is common. A Dutch study of 2157 women aged 50–75 years found that overall prevalence of vaginal dryness, soreness and dyspareunia was 27%.1 Almost half of the symptomatic women reported moderate to severe discomfort. One-third of those affected received medical care. Previous hysterectomy had no effect on the reported prevalence estimates. Hysterectomized women reported moderate to severe complaints more often than non-hysterectomized women. Smoking had no effect. A Turkish study of 500 women aged over 50 years found that 18.2% suffered from vaginal discharge and pruritus, while 23% experienced vaginal dryness.2

What are the non-hormonal options?

Lubricants and vaginal moisturizers are available without prescription. While being a popular first-line option, the number of published scientific trials is limited.

Lubricants usually consist of a combination of protectants and thickening agents in a water-soluble base. They are usually used as temporary measures to relieve vaginal dryness during intercourse. They therefore do not provide a long-term solution. Lubricants must be applied frequently for more continuous relief and require reapplication before sexual activity. The integrity and efficacy of condoms may be compromised by lubricants such as petroleum-based products and baby oil. This is important when condoms are used to prevent sexually transmitted infections (STIs).3

Moisturizers may contain a bioadhesive polycarbophil-based polymer, which attaches to mucin and epithelial cells on the vaginal wall and retains water. Moisturizers are promoted as providing long-term relief of vaginal dryness and need to be applied less frequently.4

What are the hormonal ...

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