L.J. Margesson, MD
Departments of Obstetrics & Gynecology and Medicine (Dermatology), Dartmouth Medical School, Hanover, New Hampshire, USA
Dryness and itching in the vulvovaginal area is an increasing problem as our female population ages and becomes menopausal. This dryness and itching is often the result of estrogen deficiency, and there are typically two types of treatment: Specific Therapy (or hormone replacement therapy), and Nonspecific Therapy. Dermatologists should be able to sort out the causes of the itching and irritation, and understand the approaches to therapy.
vulva, vagina, pruritus, estrogen
Dermatologists are not consulted regularly for vulvovaginal problems, but as our aging female population moves into menopause, more and more patients will be complaining of vulvovaginal itching and dryness. Those patients who already have skin conditions affecting their vulvar areas will be more susceptible to irritation and exacerbation of their skin conditions, which include inverse psoriasis, atopic and “sensitive” skin, genital lichen sclerosus, and lichen planus. Dermatologists should be able to sort out the causes of the itching and irritation, and understand the approaches to therapy.
Vulvovaginal Dryness and Itching
Vulvovaginal dryness and itching most commonly occur when there is an absence of estrogen stimulation. Estrogen is needed for the structural and functional integrity of the vagina and the introitus. Without estrogen, the first symptom is dryness. Typically, perimenopausal women develop this dryness long before hot flashes and menstrual cessation. The vagina begins to feel like “sandpaper” and may be accompanied by itching. Signs of this atrophic vulvovaginitis develop slowly and insidiously.
Perimenopause usually starts about 5-7 years before the last menstrual period, but can occur prematurely in the late twenties or thirties.1 Relative atrophy can also develop postpartum with lactation and with the use of some birth control pills. Onset may be abrupt postsurgery or after chemotherapy.2 Tamoxifen, an anti-estrogen used for treatment of breast cancer and malignant melanomas, can cause menopausal symptoms by blocking the estrogen effect in reproductive women. In postmenopausal women, it has an agonistic estrogen-like action.
Along with the dryness and itching, the other complaints of estrogen deficiency, e.g., hot flashes, insomnia, decreased libido, and psychological and cognitive changes eventually occur. Closer to the time of actual menstrual cessation, vaginal atrophic changes may increase to induce marked dyspareunia and urinary incontinence.
Poorly estrogenized vulvovaginal tissue thins, and then loses its normal vaginal secretions and normal flora. The result is an increased susceptibility to trauma from friction or chemical irritants, and to bacterial overgrowth, should it become irritated. Petechiae, telangiectasia, fissuring, and even a purulent discharge may develop. Initially there is vulval itching and then burning.
Estrogen Deficiency in Children
The effects of estrogen deficiency are often overlooked in young girls. In infancy, their genitalia are protected by maternally derived estrogen, but after the first two years of life, they are relatively estrogen deficient. There is relative atrophy, as well as a lack of the normal labial development, which become protective factors for the genital area. However, this atrophic, hypoestrogenic tissue is susceptible to irritants from urine, feces, cleansers and topical products and is susceptible to bacterial overgrowth like in an adult. One of the most common gynecological problems in children is vulvovaginitis. Many of the products used for cleansing and topical relief may just add insult to injury, creating more “contact” (usually of the primary irritant type) dermatitis.3
The Hypoestrogenized Vulva
On examination of the hypoestrogenized vulva, the vulvar trigone (the area of the vulva below the clitoris around the inside of the labia minora and around the hymenal ring) looks atrophic, pale and dry. The vaginal epithelium is dry, light pink to white, thin, and smooth due to loss of rugae. With increased severity, the vulva can show erythema, petechiae, telangiectasia, fissuring and erosion, and the open erosions may even produce a chronic purulent discharge. The pH is elevated at 6.0 – 7.0. The area around the vulva may be secondarily irritated with varying degrees of dryness, scaling and even painful fissures.4
Treatment is divided into Nonspecific Therapy (i.e., addressing all the general factors that irritate the skin and any underlying conditions that may be further complicating management) and Specific Therapy (i.e., hormone replacement therapy).
For Nonspecific Therapy, all irritating soaps and hygiene products should be discontinued along with sanitary pads, and hot constrictive synthetic clothing. Unfortunately, in addition to experiencing dryness, itchiness and irritation in the vulvovaginal area, menopausal women are also often incontinent. This is a major problem in older patients, and a very embarrassing problem that most women try to hide. They wear pads all day and consequently their vulvar area is chronically damp. Unfortunately, this “diaper dermatitis” is often missed. Patients do not volunteer such information and hide the pads during examinations. Heavy patients often wear constrictive clothing, which further complicates the problem. Because of the combination of urinary incontinence, heat, perspiration and odor, they use irritating cleansing products, “deodorants”, and wipes. It is important to take the time to obtain a full history of the products that your patients are using.
Encourage patients to use loose ventilated cotton type clothing as much as possible, avoiding pantyhose and girdles. Nonirritating cleansers like Cetaphil® lotion (Galderma) should be used to gently cleanse the area. Disposable wipes or feminine deodorant products should be discouraged. For cleansing and soothing irritation, recommend a sitz bath for 5-10 minutes, 2-3 times daily with Burow’s solution, mixing 1/2-1 packet of Domeboro® (Bayer) or Buro-Sol® (Stiefel) in 500ml water. A hand-held showerhead is invaluable for cleansing and rinsing the genital area.
If the skin is dry and cracked, use plain petrolatum or even light mineral or olive oil after the soak and while the skin is still damp. If there is mild to moderately severe pruritus and irritation, then topical l% hydrocortisone in petrolatum or triamcinolone 0.l% ointment may be necessary. Secondary infection from bacteria and yeast may require treatment, and any underlying dermatological condition must be treated. If the patient is not responding, patch testing may be necessary. If incontinence is a major problem, the patient should be referred to a urologist or gynecological urologist for pelvic floor management.
|Specific Therapy||Hormone Replacement Therapy|
Table 1: Two types of therapy recommended for treatment of atrophic vulvovaginitis.
Specific Therapy utilizes hormone replacement. However, estrogen replacement can be a confusing and complicated process, because there are many products and regimens available. Adequate estrogen levels can be achieved by taking the hormone orally, vaginally, or by a transdermal route. However, the oral or transdermal routes may not be adequate for the vagina, and a vaginal cream could still be necessary. The oral dose of estrogen needed is individualized, and can be given continuously or in a cyclic fashion, with or without the progestin. If the uterus is present, a progestin must be given to protect the vaginal lining from excess estrogen stimulation. The systemic estrogens available are estradiol, conjugated estrogen and estropipate. Recently there has been controversy about which progestational agent is safer or more effective. The two progestins are medroxyprogesterone acetate and micronized progesterone. Pure micronized progesterone is felt to be safer and more effective.
Topical replacement therapy includes estriol, conjugated estrogen and estradiol in various forms. Hormone replacement therapy is contraindicated in the presence of:
- estrogen-dependent malignancies
- breast cancer
- thromboembolic disease (The onset may be abrupt
postsurgery or after chemotherapy)
- undiagnosed vaginal bleeding
For those who cannot use hormone replacement therapy, a vaginal lubricant or moisturizer should be considered, such as Replens® (Shire Pharmaceuticals) that will last up to 72 hours. They can be very effective postpartum, during lactation and in premenopausal women.5,6,7
- McLean JM. Anatomy and physiology of the vulva. In: Ridley CM and Neill SM, editors. The Vulva. Oxford: Blackwell Science (1999) pp.58-59.
- Kaufman RH, Faro S. Miscellaneous vaginal disorders. In: Kaufman RH and Faro S, editors. Benign Diseases of the Vulva and Vagina. St. Louis: Mosby (1994) pp.367-71.
- Williams TS, Callen JP, Owen LG. Vulvar disorders in the prepubertal female. Pediatr Ann 15(8):588-605 (1986 Aug).
- Pincus SH. Vulvar dermatoses and pruritus vulvae. Dermatol Clin 10(2):297-308 (1992 Apr).
- Margesson LJ. Normal Anatomy of the Vulva. In: Fisher BK, Margesson LJ, editors. Genital Skin Disorders: Diagnosis and Treatment. St. Louis: Mosby (1998) pp.104-7.
- Lynch PJ, Edwards L. Genital Dermatology. Baltimore:Churchill Livingston (1995) pp.93-95.
- Willett WC, Colditz G, Stampfer M. Postmenopausal estrogens – opposed, unopposed, or none of the above. JAMA 283(4):534-5 (2000 Jan).
TPP – Canada Institutes Changes to Clinical Trial Regulations
TPP – Canada announced that as of September 1, 2001, some new clinical trial regulations will become effective, resulting in important and long awaited changes in both the clinical trial review and conduct in Canada. These changes include:
- Some Phase I protocols (e.g., bioequivalence, or trials involving healthy volunteers) will have an internal target review time of seven calendar days.
- Following submission of an Investigational New Drug application (IND), the waiting period will be 30 days instead of 60 days.
- Only qualified investigators (i.e., physicians or dentists who are licensed to practice) can undertake clinical trials.
- Prior to starting a clinical trial, the sponsor must supply the names of all Ethics Review Boards and their conclusions
- Clinical trial sites in Canada will be open to TPP inspection and review.
- All clinical trials must be conducted following Good Clinical Practice standards, even trials not requiring an IND.
These changes will have a major impact on how clinical trials will be carried out in the future.