Vaginal Itching

Abstract: Objective To support the practitioner in the diagnosis of vaginal atrophy and in the management of the related symptoms. Options The modalities of evaluation range from basic pelvic examination, examination of the vulva, and laboratory tests. Outcomes A comprehensive approach to the detection of vaginal atrophy and a discussion of available therapeutic and nontherapeutic options. Evidence Published opinions of experts, supplemented by evidence from clinical trials, where appropriate. Values The quality of the evidence is rated using the criteria described by the Canadian Task Force on the Periodic Health Examination. Benefits, harms, and costs Diagnosis of vaginal atrophy is often a challenge because women are unwilling to report symptoms, which have the potential to significantly decrease their quality of life. Increased clinical suspicion is the first step in the diagnosis of vaginal atrophy, which will prompt the initiation of safe therapies with proven efficacy. Recommendations 1. Health-care providers should routinely assess postmenopausal women for the symptoms and signs of vaginal atrophy, a common condition that exerts significant negative effects on quality of life. (III-C) 2. Regular sexual activity should be encouraged to maintain vaginal health. (II-2B)3. Women experiencing recurrent urinary tract infections should be instructed that consumption of pure cranberry-lingonberry juice, rather than cranberry drink, will decrease their risk of urinary tract infections. (I-A) 4. Vaginal moisturizers applied on a regular basis have an efficacy equivalent to local hormone replacement for the treatment of local urogenital symptoms such as vaginal itching, irritation, and dyspareunia, and should be offered to women wishing to avoid use of hormone replacement therapy. (I-A) 5. Women experiencing vaginal atrophy can be offered any of the following effective vaginal estrogen replacement therapies: conjugated equine estrogen cream (I-A), a sustained-release intravaginal estradiol ring (I-A), or a low-dose estradiol tablet (I-A). 6. Although systemic absorption of estrogen can occur with local preparations, there is insufficient data to recommend annual endometrial surveillance in asymptomatic women using local estrogens. (III-C) 7. For menopausal women experiencing recurrent urinary tract infections and who have no contraindication to local hormone replacement, vaginal estrogen therapy should be offered. (I-A).

Abstract: A gradual decrease in the production of oestrogens from the ovaries is seen in the perimenopausal years, ultimately leading to the menopause. Symptoms of vaginal atrophy result from a combination of atrophic changes in the oestrogen dependent cells that line the vagina and a reduction in the secretion of cervical mucus, which circulates in the vaginal lumen.1 The administration of exogenous oestrogens (either systemic or topical) is a common treatment for symptoms related to vaginal atrophy.2 Under the influence of oestrogens, maturation of the vaginal epithelium is restored. However, the use of exogenous oestrogens has several adverse effects, and may therefore be contraindicated.2,3 Replens™, a polycarbophil based vaginal moisturiser, is a non-hormonal alternative to oestrogen treatment. A characteristic of this bioadhesive polymer is that it is water insoluble, but water swellable. When applied intravaginally it binds to the vaginal epithelium, releasing purified water to hydrate the underlying cells.4 The gel produces a moist film over the vaginal tissue, which remains attached to the epithelial cell surface. The hydration of the epithelium lubricates the vaginal wall and reduces the incidence of vaginal itching, irritation, and dyspareunia.3 Furthermore, Replens restores the vaginal pH to premenopausal values.2 “Replens™, a polycarbophil based vaginal moisturiser, is a non-hormonal alternative to oestrogen treatment” Whereas the clinical effect of Replens has been shown in multiple clinical studies (VV Ragavan et al. Presented at the international congress on the menopause, Sydney, Australia, 3–7 November 1996),2–5 the effect of Replens on vaginal cytology has not yet been studied extensively. In a comparative study of Replens versus the administration of local oestrogens, nine of 15 women using Replens for 12 weeks showed reversal of atrophy in Papanicolaou stained vaginal smears.2 In a study on baboons with decreasing ovarian function, a significant improvement of histological features was observed in biopsy specimens of the vaginal epithelium after five days of Replens use.4 In a study treating 25 patients suffering from breast cancer with Replens, a significant decrease of atrophic, crowded, parabasal cells in vaginal smears was found after three months of treatment (VV Ragavan et al. Presented at the international congress on the menopause, Sydney, Australia, 3–7 November 1996). In addition, cells appeared to be larger after treatment with Replens. These data suggest increased maturation of the vaginal epithelium as a result of Replens. To our knowledge, no previous study has focused on the effect of Replens on the morphology of cells in vaginal smears. Improvement of the maturation of subsequent vaginal smears may be studied using the maturation index (MI).6 The MI expresses the percentages of (para)basal, intermediate, and superficial cells in a predetermined number of cells in a smear. Manual assessment of the MI by an experienced cytotechnologist was found to show limited reproducibility.7 A method using cytomorphometric analysis (CMA) to assess the degree of maturation in vaginal smears has been described previously.7 This method showed better reproducibility than the classic manual method. Furthermore, when using CMA additional morphometric parameters can be obtained, which may reveal more subtle changes. A shift in the degree of maturation, expressed in the MI, of consecutive vaginal smears would be indicative of an oestrogen-like cytological effect of Replens on the vaginal epithelium. In our study we chose to evaluate, by both manual assessment and CMA, the effect of Replens on vaginal cytology in a group of postmenopausal women with symptoms related to vaginal atrophy. Vaginal smears were taken before and after 12 weeks of treatment, and maturation of the samples was assessed by manual assessment and CMA. The improvement of vaginal maturation after 12 weeks, as compared with baseline, was studied. The aims of our study were: (1) to study the effect of Replens on the maturation of the vaginal epithelium and the morphology of vaginal cells and (2) to assess the degree of maturation of the vaginal epithelium using an automated method compared with a manual method.

Abstract: Objective: This study aimed to examine factors other than estrogen deficiency influencing the development and persistence of vaginal dryness, itching, and painful sexual intercourse after menopause. Methods: We analyzed data from a 2-year, population-based cohort of 1,017 postmenopausal women aged 55 to 75 years. Vaginal symptoms were assessed by interviewer-administered questionnaire, and vaginal swabs were performed to assess vaginal pH and microbial flora at baseline, 12 months, and 24 months. Generalized estimating equations were used to identify characteristics associated with symptoms. Results: Half of the women (n = 471) reported problematic vaginal dryness, a third (n = 316) reported itching, and 40% of sexually active women (n = 166) reported painful intercourse at baseline. Of women not taking estrogen, half of those reporting baseline symptoms were symptomatic after 24 months. Vaginal dryness was associated with younger age (odds ratio [OR], 0.81; 95% CI, 0.69-0.94, per 5-y increase), nonwhite race (ie, African American, Hispanic, Asian or Pacific Islander, or American Indian [OR, 1.53; 95% CI, 1.04-2.27]), diabetes (OR, 1.51; 95% CI, 1.07-2.12), lower 36-item Short-Form Health Survey physical functioning scores (OR, 0.90; 95% CI, 0.85-0.97, per 10-point increase), lower body mass index (OR, 0.81; 95% CI, 0.71-0.93, per 5 kg/m 2 increase), recent sexual activity (OR, 1.14; 95% CI, 1.08-1.21), and vaginal colonization with enterococci (OR, 1.25; 95% CI, 1.04-1.51). Vaginal itching was also associated with lower physical functioning scores (OR, 0.86; 95% CI, 0.80-0.92, per 10-point increase). Risk factors for painful intercourse included younger age (OR, 0.72; 95% CI, 0.56-0.93, per 5-y increase), diabetes (OR, 3.48; 95% CI, 1.93-6.27), lower body mass index (OR, 0.76; 95% CI, 0.61-0.95, per 5 kg/m 2 increase), and higher vaginal pH (OR, 1.10; 95% CI, 1.00-1.21, per 0.5 units). Conclusions: Vaginal symptoms affect a large proportion of postmenopausal women, particularly those with diabetes and those with lower body mass index, but may resolve for up to half of women without estrogen therapy.