Age-related changes in women can cause an increase in the occurrence of vulvovaginal dermatological conditions such as vulvar dermatitis and lichen sclerosis, as well as associated problems such as urinary incontinence, recurrent urinary tract infection and sexual dysfunction. During and after menopause due to decreased estrogen levels can result in a range of symptoms, including atrophic changes, vaginal dryness and irritation, and may also increase susceptibility to vulvovaginal trauma and infection. Vulvovaginal atrophy occurs due to decreased estrogen levels.
Estrogen is the primary hormone that regulates the physiology of vulvovaginal tissues. As a woman ages, the gradual decline in circulating estradiol that begins in the peri-menopausal period causes a number of changes that can affect the health of the genitourinary tract. The natural sensitivity of vulvovaginal skin, progressive estrogen deficiency, and the proximity of the urethral opening and anus, along with aging skin changes, make conditions that affect the vulvovaginal skin common and become a cause of distress for many postmenopausal women. Changes that occur with advancing age and with decreasing estrogen levels include:
Vulval tissue atrophy – thinning of the skin, subcutaneous fat atrophy, reduced hair growth
• Atrophy of the vagina – narrowing and shortening of the vagina with the narrowing of the introitus. Due to the reduction of rugal folds, the lining of the vagina tends to become thinner, less elastic, and smoother.
Atrophy of all other estrogen-dependent tissues, eg pelvic floor muscles, urethral mucosa, uterus, ovaries
• Decreased vascularity
Decreased vaginal secretion
• Changes in vaginal microflora – reduced glycogen from vaginal epithelial cells causes a change in the pH of the vagina that is more basic than acidic (typically> 5.0). The change in pH is detrimental to the survival of acid-producing bacteria (eg Lactobacilli) and can lead to further changes in pH and microflora.
Vulvovaginal atrophy is the term used to describe specific atrophic changes in the vulva and vagina that progressively occur in all women after menopause. It is also considered a condition in its own right, as the characteristic changes due to reduced estrogen can result in a range of symptoms such as vaginal dryness, irritation, and discomfort. Atrophic changes also make vulvovaginal skin more vulnerable to trauma and infection.
Other vulvovaginal conditions become more common after menopause. In addition to vulvovaginal atrophy, a number of other conditions become more common after menopause, such as vulvar dermatitis, lichen sclerosis, and less commonly lichen planus. Lichen simplex can also occur in postmenopausal women, but occurs in younger women. The pattern of symptoms resulting from these conditions can often be similar, and most women experience itching as the primary symptom. However, the nonspecific nature of the symptoms present can make it difficult to distinguish between the various conditions.
In some women, more than one vulvar condition may be present at the same time, or an underlying more general dermatological condition, such as psoriasis. Itching from primary dermatosis can lead to itching and extreme hygienic measures, leading to secondary lichen simplex and irritating contact dermatitis. Therefore, if an initial treatment regimen fails to produce an improvement in symptoms, other diagnoses should be considered. 2 In some patients it may be difficult to diagnose, so if the vulvar disorder has not responded, it is usually recommended to refer to a Dermatologist or Gynecologist (preferably with a special interest in vulvar dermatoses) to confirm the diagnosis and begin primary care.
Atrophy of estrogen-dependent tissues can contribute to other gynecological problems in postmenopausal women, including uterine prolapse, urinary incontinence. These factors can be listed as follows;
Incontinence is a risk factor for skin lesions
Recurrent urinary tract infections
• Recurring UTIs
Vulvovaginal candidiasis in postmenopausal women
Problems with bacterial vaginosis
For a variety of reasons, sexually transmitted infections (STIs) are generally not considered a diagnosis in older women. However, many women after menopause continue to be sexually active and may have a higher risk of STIs due to increased susceptibility to infection (as a result of atrophic change) and lack of condom use, especially in single women. Women may also have concerns about sexual function, as vulvovaginal atrophy and vulva can be affected by skin conditions.
Many women may be reluctant to talk to a healthcare professional about vulva or vaginal problems and may use over-the-counter products to relieve vulvovaginal symptoms initially. It is estimated that only 25-50% of women with vulvovaginal symptoms seek help from their GP. Research has shown that there are many reasons why women do not seek help, including:
Feeling embarrassing, uncomfortable or private
Believing that aging is a normal part
Not being aware that there are treatments available
Not knowing how to start a conversation about these issues
Recognizing that changes in vulvovaginal health are an expected part of aging and initiating a conversation about the presence of any symptoms can encourage women to share their concerns and be more open about treatment options. Some women may not explain that they have a skin condition affecting the vulva because they are uncomfortable or embarrassed by the need for clinical examination of the vulvovaginal area. Their concerns should be acknowledged and, if appropriate, other options may be offered, for example if the normal GP is a male, a female GP should be seen in the practice.
Writer: Ozlem Guvenc Agaoglu