WHITE SULPHUR SPRINGS, W.VA. — Within just 6-12 months of discontinuing hormone therapy, more than 96% of postmenopausal women will show altered vaginal pH, a marker for tissue change and its associated genital atrophy, Murray Freedman, M.D., reported.
Only 10 of 300 women maintained a normal vaginal pH of 4.5 or less after discontinuing HT use, and seven of those women had elevated serum estradiol levels related to obesity-driven estrogen production, said Dr. Freedman, of the Medical College of Georgia, Augusta.
The rest of the women had both elevated vaginal pH and decreased serum estradiol. The most common clinical finding in the study was involution of the vulvar structures and a rapidly occurring introital stenosis, which correlated with frequent complaints of dyspareunia, he noted at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.
Because the onset of genital atrophy is insidious and its measurement subjective, the number who experienced it was “hard to quantify,” Dr. Freedman said in an interview. “There is no real measurement for it. But for many of these women, the stenosis became noticeable within 6-12 months.”
Dr. Freedman's observations have led him to conclude that the dyspareunia many postmenopausal women experience has more to do with introital stenosis than with vaginal dryness. “The dryness was secondary to the stenosis and the involution of the distal vagina. Once you got past the introitus, the upper vagina was uncompromised.”
His prospective observational study evaluated a total of 300 women who had discontinued hormone therapy after publication of the initial Women's Health Initiative results in July 2002. All women underwent a pelvic exam and had their vaginal pH tested within 12 months of therapy discontinuation (most within 6 months). Those women with a normal vaginal pH level (4.5 or below) had their serum estradiol level evaluated.
The vast majority of the women (290) had a pH level of more than 4.5. Only 10 maintained a normal vaginal pH. Three of those women had serum estradiol of less than 20 pcg/mL, consistent with postmenopausal status.
The other seven had normal circulating estradiol levels. One of these was a 50-year-old woman with her uterus, fallopian tubes, and ovaries intact, who had been placed on HT for menopausal symptoms. The other six women were older (57-76 years) and either overweight or obese. “Their normal estrogen levels and the resulting normal vaginal pH were due to a high production of endogenous estrogen secondary to obesity,” Dr. Freedman said.
In addition to observing introital stenosis, he noted that the urethral meatus became more prominent in many women, assuming almost a tubular form and expanding to constitute up to two-thirds of the introitus. This is not surprising, he said, because the urethra and trigone are just as heavily endowed with estrogen receptors as are the lower vagina and vulva and just as susceptible to involutional change with estrogen deficiency.
“Embryologically, the vulva, distal vagina, trigone, and urethra are all derived from the urogenital sinus and contain the highest concentration of estrogen receptors. The upper vagina is actually a downgrowth of the müllerian system” and so less susceptible to change associated with estrogen depletion.
Because genital atrophy is so widespread and rapid after menopause in the absence of HT, women should be proactively counseled about how to maintain good genital health. If the decision is made to discontinue HT, topical estrogen can prevent genital atrophy and, if administered within the first year of estrogen cessation, can even reverse some changes.
Coitus at least once a week helps maintain tissue integrity by dilation and increased genital blood flow. “In the absence of both estrogen and sexual activity, the rapidity of involution is compounded,” he said.
Women who do not have a male partner can be counseled to use topical estrogen and a vibrator or vaginal dilator, and to become orgasmic, periodically. “This will maintain a normal, healthy vagina,” Dr. Freedman said.
However, he continued, most physicians — especially males — never really broach the subject of sexuality with their postmenopausal patients.
“To those men, I would put this question: 'At what age would you like your genitalia to begin shrinking?'” Dr. Freedman said. “I bet it wouldn't be 51, which is the average age of menopause in this country.”
This 55-year-old who quit HT a year ago exhibits almost total involution of the genitalia. Courtesy Dr. Murray Freedman