Post Menopausal Atrophy - Vulval Skin Disorders

This video, titled "Post Menopausal Atrophy - Vulval Skin Disorders" by Gynae Consultant, explains the biological changes, common symptoms, and management options for vulvovaginal atrophy caused by estrogen deficiency.

Understanding the Biological Changes

• Embryological Context: The lower urogenital tract and the lower alimentary tract (near the anus) share the same embryological origin. Because they develop as a unit, dermatological conditions often affect the entire area simultaneously.
• Skin Alterations: The drop in estrogen levels following menopause triggers several physiological changes in the vulval skin texture:
  • Thinning and atrophy of the dermal layer.
  • Reduced localized blood flow.
  • A loss of essential collagen, elastin, and hyalinization.
  • Consequently, the skin becomes pale, shiny, dry, and friable (easily irritated or torn).
• Shift in Vaginal Flora: Estrogen loss leads to a depletion of glycogen within vaginal cells. This disrupts the healthy microflora, causing a decline in protective Lactobacillus bacteria. Other bacteria take over, which frequently induces irritation, abnormal discharge, and an increased risk of infections.

Timeline of Symptoms

Symptoms typically progress in stages as estrogen deficiency persists over time:

• Initial Post-Menopause Phase: Vaginal dryness and superficial dyspareunia (pain during intercourse) are the primary complaints. However, evidence suggests that arousal difficulties at this early stage play an equally significant role alongside the physical lack of estrogen.
• Advanced Phase (Around 3 Years Post-Menopause): Due to long-term estrogen deprivation, constant itching, generalized physical discomfort, and localized pain become the dominant everyday symptoms.

Management and Treatment Options

First-Line Care & Routine Adjustments

• Moisturizers & Lubricants: Regular use of dedicated vaginal moisturizers provides daily comfort, while targeted lubricants help manage pain during sexual activity.
• Irritant Avoidance: Patients should eliminate potential irritants, including synthetic or nylon underwear, perfumed products, and harsh soaps.
• Soap Alternatives: Standard soaps should be replaced entirely with gentle emollient alternatives. If local skin reactions persist despite these adjustments, patch testing may be required to rule out allergic or irritant contact dermatitis.

Second-Line Medical Therapy

• Topical Estrogen: When basic skin care and over-the-counter moisturizers are insufficient, targeted topical estrogen therapy is recommended. This can be administered in several localized forms depending on patient preference, including:
  • Creams
  • Pessaries
  • Vaginal tablets
  • Sustained-release vaginal rings