Postmenopausal vulva and vagina

Abstract

Postmenopausal hypoestrogenism often manifests as vulvovaginal atrophy. The labia shrinks, the introitus narrows, the vagina shortens, and the vaginal mucosa becomes more friable; vaginal pH rises, the microbiota composition is altered, and discharge becomes sparse. These atrophic changes cause vulvar and coital discomfort and also result in a higher risk of urinary tract infections in women with a prior history. Intravaginal estrogen creams and tablets alleviate symptoms of atrophy and restore the characteristics of the vaginal mucosa while limiting systemic effects. Urinary changes also become more common as women age. Stress incontinence is voiding provoked by pressure on the bladder sphincter. Kegel exercises strengthening the pelvic muscle are a conservative treatment. Urge incontinence is uncontrolled urine loss spurred by feelings of urgency that may be caused by abnormal bladder spasms. Interstitial cystitis, thought to involve the leakage of potassium ion across a compromised mucosal barrier, mimics the symptomology of frequent voiding at low volumes observed with urge incontinence. Urge incontinence is treated by behavioral modifications, changes in diet, and antimuscarinic drugs. In the frail older woman with incontinence, vigilant perineal care is needed to prevent the development of incontinence dermatitis. Lichen sclerosus, an uncommon vulvar dermatosis, is an eruption of itchy white papules bilaterally on the vulvar skin and mucosa. A classic presentation is a “figure-eight†configuration of sclerotic tissue around the introitus and anus. Erosive lichen planus, a dermatosis of the mucosa only, and desquamative vaginitis, a bacterial vaginal infection, are two rare conditions which lead to desquamation of the vaginal epithelium and require aggressive antibiotic and corticosteroid treatment, respectively, to limit mucosal deterioration.