The vulva the external genital of the female includes the mons pubis, labia majora, labia minora, clitoris, vestibule and vestibular glands of the vagina. Except the mons pubis and labia majora vulva surfaces are lined by a moist stratified squamous epithelium. This natural moisture keeps the labia, vulva area comfortable and functioning well (much like moisture keeps the eyes comfortable).
Vulvovaginal atrophy is a common condition, especially in postmenopausal women. Vaginal atrophy, atrophic vaginitis, and urogenital atrophy are other terms used to describe a constellation of symptoms associated with decreased estrogenization of the vulvovaginal tissue.
Common symptoms include vaginal dryness, irritation, light bleeding and soreness after sex. These symptoms may be associated with vaginal discharge and dyspareunia (painful intercourse). Urinary symptoms associated with vulvovaginal atrophy include frequency, urgency, and urge incontinence.
Clinical findings include atrophy (thinning) of the labia majora and vaginal opening (introitus). The labia minora may recede. Vulvar and vaginal mucosae may appear pale, shiny, and dry; if there is inflammation, the vulva and/or vagina tissue may appear reddened or pale with petechiae. Vaginal rugae disappear, and the cervix may become flush with the vaginal wall. Vaginal shortening and narrowing tend to occur. Petechiae are tiny pinpoint spots that appear on the skin as a result of bleeding under the skin.
Vulvovaginal atrophy can occur at any time in a woman’s life cycle, although it is more common in the postmenopausal phase; a time of low estrogen (hypo-estrogenism). Other causes of a hypo-estrogenic state include lactation, various breast cancer treatments (Arimidex, Tamoxifen), and use of certain medications. In situations other than menopause, vulvovaginal may resolve spontaneously when estrogen levels are restored.
Numerous retrospective studies have evaluated the prevalence of symptoms of VVA. Although these studies differ in type of symptoms elicited, study design, and study population, they provide a range of estimates of vulvovaginal atrophy prevalence. They all used self-reported symptoms of vaginal dryness to determine the prevalence of VVA. In general, the prevalence ranged from about 4% in the early premenopausal groups to 47% in the late postmenopausal group.
The prevalence of vulvovaginal atrophy in some subgroups of women can be much higher. In a cohort of breast cancer survivors, vaginal dryness was present in 23.4% of the premenopausal patients and in 61.5% of the postmenopausal patients.
Vulvovaginal atrophy occurs under conditions of low estrogen (hypoestrogenism).
● premenopausal estradiol levels fluctuate from 10 to 800 pg/mL depending on when measured during the menstrual cycle.
● postmenopausal estradiol levels are typically less than 30 pg/mL.
After menopause, circulating estradiol derives from estrone, which is peripherally converted in fat tissue from adrenal androstenedione.
Vaginal Structure and Function
The vaginal epithelium is a stratified squamous epithelium, which until menopause is moist and thick with rugae. At menopause, with declining levels of estrogen, the vaginal epithelium thins. Fewer epithelial cells result in less exfoliation of cells into the vagina. As epithelial cells exfoliate and die, they release glycogen, which is hydrolyzed to glucose. Glucose, in turn, is broken down into lactic acid by the action of lactobacillus, a normal vaginal commensal organism. Without this cascade, the pH in the vagina rises, resulting in a loss of lactobacilli and an overgrowth of other bacteria, including group B streptococcus, staphylococci, coliforms, and diphtheroids. These bacteria can cause symptomatic vaginal infections and inflammation. After menopause, the elasticity of the vagina is reduced and connective tissue increases. A decline in estrogen level causes a decrease in vaginal blood flow and a decrease in vaginal lubrication.
The effects of endogenous estrogens on vulvovaginal tissues are mediated through estrogen receptors (ERs) α and β, found at sites throughout the urogenital area, including the vagina, vulva, labia, urethra, and bladder trigone.
Above Info Sourced from: Vulvovaginal Atrophy
Maire B. Mac Bride, MBBCh, Deborah J. Rhodes, MD, and Lynne T. Shuster, MD. Mayo Clin Proc. 2010 January; 85(1): 87–94.
Helpful Note: Unlike hot flashes, and heart palpitations which tend to ease during the menopause transition, vulva and/or vaginal atrophy does not lessen over time. This is because the vulva and vaginal structure have changed as a direct result of diminished ovarian estrogen production due to menopause.
It is helpful to distinguish the vulva from the vagina because these genital areas have different tissue structure and function. Vagina discomfort is felt with penetration . . . during intercourse. Vulva, labia dryness, irritation and soreness can be felt throughout the day.
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DISCLAIMER: Kátha Soma does not provide medical advice, diagnosis or treatment. The information provided is neither intended nor implied to be a substitute for professional medical advice. Seek the advice of a physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.