Description

• Estrogen-deficient vulvovaginitis is a hypoestrogenic state with external genital, urologic, and sexual sequelae.
• Estrogen deficiency affects all tissues in the female body; however, the genital tissues are especially hormone responsive and are most affected.
• Decreased estrogen leads to decreased blood flow to vaginal tissues and thinning of vaginal tissues, dryness, and atrophy. Patients with estrogen-deficient vulvovaginitis may present with urinary incontinence, vaginal burning and itching, dyspareunia, increased urinary frequency, recurrent UTIs, or various other symptoms.
• This condition is also referred to as genitourinary syndrome of menopause when associated with the postmenopausal state, although this condition may occur in women of all ages.
• System(s) affected: reproductive

Epidemiology

Incidence
Predominant age: postmenopausal females. The average age of menopause in the United States is 51.3 years but ranges from 45 to 55 years old.

Prevalence

• Approximately 40–54% of postmenopausal women are affected.
• Approximately 15% of premenopausal women are also affected.
• This condition is likely underdiagnosed because patients may be reluctant to report symptoms because of embarrassment or the misconception that symptoms should be accepted as a natural part of aging (1).

Etiology and Pathophysiology

• Estrogen is vasoactive, increasing blood flow to target tissues, lubrication, and elasticity.
• Decreased estrogen levels in the vagina and vulva result in decreased blood flow and decreased lubrication and elasticity of vaginal and vulvar tissues as well as thinning of these tissues.
• Decreased cellular maturation results in decreased glycogen stores, which affects the normal vaginal flora and consequently the pH.
• The resulting increased pH impairs the viability of the normal flora, permitting the proliferation of fecal and other flora, resulting in UTIs and vaginal infections (1)[C].
• Estrogen deficiency is caused by the following:
  • Menopause (surgical or natural)
  • Premature ovarian failure (chemotherapy, radiation, autoimmune, anorexia, genetic)
  • Postpartum estrogen deficiency in lactating women
  • Medications that alter hormonal concentration, such as gonadotropin-releasing hormone agonists, tamoxifen, danazol, medroxyprogesterone, and aromatase inhibitors
  • Elevated prolactin from hypothalamic–pituitary disorders

Genetics
No known pattern

Risk Factors

• Estrogen-deficient states, including lactation
• Smoking
• Alcohol abuse
• Sexual abstinence or decreased frequency of coital activity
• Lack of exercise
• Absence of vaginal childbirth
• Chemotherapy
• Radiation therapy

Commonly Associated Conditions

• Urge and stress urinary incontinence
• Pelvic organ prolapse
• Frequent UTIs
• Bacterial or fungal vulvovaginitis
• Vaginal stenosis
• Loss of libido
• Dyspareunia