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5 September 2004 Interview with Prof John Eden of the Royal Hospital for Women, Sydney (Australia)
What is atrophic vaginitis? What are the symptoms?
John Eden: “Atrophic vaginitis means that the vagina has become very thin. It is basically due to a lack of oestrogen. For the vagina to maintain its normal thickness and moisture it needs to have oestrogen. In about half of women after they start menopause and oestrogen levels fall, they will develop some degree of atrophic vaginitis. Certainly surveys around the world, and in particular one we did in Australia1, show that about half of women begin to notice symptoms of atrophic vaginitis around menopause. By far the most common symptom is pain with sex, but there also can be irritation, a burning sensation, an unpleasant vaginal discharge and in a few cases there can even be bleeding. Menopause is the biggest cause, but there are other causes. “ You mention that in addition to menopause, there are other causes. Can you talk about some of the other reasons for atrophic vaginitis?
John Eden: “Any condition that can cause a lack of oestrogen can cause atrophic vaginitis. So for example in young women who stop menstruating, probably the most common cause for this group would be anorexia, but there are drugs or pituitary problems that can result in vaginal dryness. Also chemotherapy, radiation therapy, surgical removal of the ovaries or anything that can cause a lack of oestrogen could result in this problem.
“It is becoming more of a problem with low dose contraceptive pills. We don’t have this problem in Australia as the lowest dose we prescribe is 20-micrograms oestrogen. But colleagues have told me that in 15 micrograms and lower dosages, atrophic vaginitis is a real problem, in about 22% of patients. This is becoming a bigger problem on the world scene as contraceptive pills have become weaker in terms of oestrogen dose. Now young women are beginning to notice this as a problem too. There is also a growing tendency to use progesterone-only contraceptives, and probably about one in five women using these will notice symptoms of atrophic vaginitis. This is definitely a symptom that could need topical treatment.
“Additionally soap can make the problem worse. Sometimes women using local HRT are still sore and wonder why. Almost always it is due to soap. As you get older your skin ages and thins. Although women use creams on their face and soap-free washes for their body, they often use a bar of soap for the vulva, which is terrible. They should use a soap-free wash and low allergenic products without perfumes.” Considering the Australian population study you referred to earlier, although there was an increase in the incidence of atrophic vaginitis with age, there was a decrease in the use of hormone replacement therapy (HRT). Why do you think this occurred?
John Eden: “The main reason for using HRT is to treat flushes which for most women is from 45 to 55 years of age, although there are some women who flush forever. Generally women get through the flush stage, stop their HRT and then they realize they have this other problem. “ After women have stopped their HRT therapy for vasomotor symptoms, does atrophic vaginitis emerge as a common problem?
John Eden: “Absolutely, we are seeing lots of that. There is still incredible ignorance about vaginal dryness being a treatable symptom of menopause. Many women believe it is an inevitable part of aging that they must simply put up with and they are pleasantly surprised when they find there is a very simple solution. Every day I tell women about local HRT and they are so happy to learn that they don’t have to put up with it. They simply do not know it is a treatable condition. For a lot of women all they need is a topical oestrogen to relieve the symptoms.” You mention that there is still a lack of patient knowledge on local HRT and in your population study only 9% of Australian women were aware that vaginal dryness is a treatable symptom of menopause. What can be done to increase women’s awareness that there is a topical local treatment for these symptoms?
John Eden: “Well, when talking to the media for example, which is the main way most people get their information, nobody talks about the vagina. Even though we live in a so-called Modern Society, it is certainly not something that is talked about. It’s ok to talk about flushes, aches, pains and osteoporosis, but vaginal dryness? It’s a tough one, how do you get through that barrier? Most of the journalists don’t want to cover it, or at least their editors don’t.” As women of today are expecting to have fuller active lives, no matter what their age, do you expect there are more women seeking a solution to vaginal dryness?
John Eden: “Yes, in fact there is evidence in Australia. After a campaign to make women aware of local HRT, there was a dramatic increase in prescriptions. This is not unique. For example, incontinence is another silent problem. When these problems are mentioned to women, they are delighted to learn that you can actually fix it. As a doctor when I raise the issue of vaginal dryness, patients are delighted to talk about it. They are really happy once you raise it.” Aren’t incontinence and atrophic vaginitis often linked in postmenopausal women?
John Eden: “Yes, generally if the vagina gets thin, the urethra and bits of the bladder are thinning as well. They go together and then additionally women can often get recurrent urinary tract infections. Basically if you have a healthy vagina that has an acidic ph and is moist, it keeps the bowel germs out. Once you lose the moisture and the ph goes to neutral, the E-coli and bowel germs can get into the vagina and are near the urethra, particularly during intercourse. So often the urologists will do a cystoscopy and find nothing. Even they know to prescribe a topical oestrogen. It is ‘the’ treatment and works on three problems at once.” Are general physicians aware of local HRT for this atrophic vaginitis and are they willing to bring up the topic with patients?
John Eden: “I am sure doctors are aware of the problem, but in a busy general practice it may be a very, very low priority. In the case of a full time hormone practice, like my situation, I am seeing a lot of patients coming in that are not on topical oestrogens and they should be. The prescription easily could have been issued by the GP, but because they are so busy it gets overlooked. Women shouldn’t have to see a specialist to have this problem solved.” What about types of treatments for atrophic vagitinitis?
John Eden: “Broadly there are two to three types of treatments and most women are using lubricants, which are very ineffectual and messy. KY Jelly for example is designed for PAP smears. It is water based and disappears after about 30 seconds. When it dries, it dries a bit like shards of glass. Obviously it is not a very good lubricant for sexual intercourse, but that is mainly what they are using. They go to the chemist and ask, ‘What can I use?’ and the chemist tells them to use this. They are not approaching the specialist. Then there are a few vaginal moisturisers; none of them are terribly good. The main treatment is topical oestrogen. There is the intervaginal tablet, Vagifem. Then there are creams and pessaries; and when women see these they recognise them as equivalent to thrush treatments. The cream is just as messy as a thrush cream and the pessaries are about the same size as a thrush ovual. Women hate them. The intravaginal tablets are much more popular. Certainly there is no doubt about that the vast majority see the mess of the creams and pessaries as a problem. They work, but they tend to leak and are very unpleasant. As a gynaecologist, I present the treatment options and my patients prefer the intravaginal tablet. It’s a no-show when you show them the cream versus Vagifem. They push the cream away and say, ‘Why are you showing me that?’ ” References: 1. Eden J. Local ERT for female sexual dysfunction? Vaginal Problems after the Menopause – the Australian Experience. Novo Nordisk International Symposium, 6 September 2003
    
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