INTRODUCTION:

Vulvovaginal atrophy (VVA) or atrophic vaginitis is a medical challenge because it is under-reported by women, under-recognized by health-care providers and, therefore, under-treated. About 50% of postmenopausal women report vaginal discomfort caused by VVA.

Recent studies indicate that when vaginal discomfort is clinically important, health care practitioners should be proactive in encouraging their patients to reveal the symptoms of VVA and seek the appropriate therapy.

VVA is a chronic illness that significantly affects sexual health and quality of life, although few women are aware of this. As a result, we require a universally applicable and cheap test that would allow for pre symptomatic identification in order to identify and monitor patients at risk¹.

For these reasons, the screening of vaginal maturation index (VMI) and vaginal pH by vaginal atrophy screening combistick is an attractive tool for assessing overall hormone status in clinical research, especially research looking at response to hormone therapy and sexual functioning during menopause². Vaginal cytology has been used widely as an outcome in clinical trials of postmenopausal hormone therapy.

OBJECTIVE:

To comprehensively review and critically assess the literature on vaginal atrophy and screening modalities.

WHAT IS VAGINAL ATROPHY?

As women enter menopause, they experience many changes, including changes to the vaginal epithelium. The epithelium (vaginal) is composed of deep immature parabasal cells, intermediate cells, and mature superficial cells. Before menarche, the vaginal cytology is composed primarily of cells (parabasal) and a smaller percentage of intermediate cells. During the reproductive years, superficial cells increase in prominence, and normally no cells seen on vaginal smears are parabasal. In the postmenopausal period, the majority of cells seen on a vaginal smear are again parabasal with fewer intermediate and superficial cells³. The symptoms of vaginal atrophy also have an impact on sexual function, quality of life, and the urinary system. For instance, sexual symptoms (such as dyspareunia and other sexual dysfunctions) and urine symptoms (such as dysuria, frequency, urgency, haematuria, and recurring urinary infections)⁴.

PATHOPHYSIOLOGY:

Natural menopause occurs between 51 and 52 years of age and the increased life expectancy means that most women will have postmenopausal symptoms for at least a third of their entire lives, a hypo estrogenic state⁵. Menopausal Syndrome is a multidimensional phenomenon in which biological variables are modulated by intrapersonal and interpersonal factors varying according to the socio cultural environment and the health-care system vulvo-vaginal atrophy is among the several changes occurring after menopause as a result of the loss of estrogen production by the aging ovaries⁶. It may occur as a consequence of other hypo estrogenic states but this is less common^7,8. Throughout the menopausal transition and beyond, VVA has a chronic progressive tendency, in contrast to hot flushes, which typically subside with time ^9,10. The existence and intensity of symptoms can range from minor discomfort to severe impairment, and they can also rely on factors such as age, the type and timing of menopause, parity, vaginal delivery, the frequency of sexual activity, cigarette smoking, and certain medical problems or drugs^11-17.

Figure-1: Normal Vaginal Epithelium

Figure 2: Cross section of vaginal epithelium in a post-menopausal woman

MATERIAL AND METHOD:

A search was carried out for trial studies published in Pubmed without time and language limitations. Medical Subject Headings (MeSh) terms are used to search databases. It should be noted that the sole language of the searched papers was English. For finding other relevant studies, lists of references in the retrieved papers were also skimmed. The time period was taken for 25 years from 1995 to 2021. The reference lists of retrieved research and pertinent reviews are also hand-searched to include new suitable studies, and the process above is repeated until no more articles are found. The criteria for inclusion are -

1. The study population is the peri-menopausal women in the age group of 40 to 65 years.

2. The modalities of screening range from basic pelvic examination, examination of the vulva, and laboratory tests.

3. Published and unpublished non-randomized and RCTs that compared the different techniques of vaginal screening for vaginal atrophy were considered in this study.

The fact that all analyses are based on already published studies eliminates the need for ethical review and patient permission. On our search, we found 8(eight) RCTs from 1995 to 2021 that comes under the inclusion criteria of this study.

REVIEW FINDINGS:

1. According to Rossella E. Nappi et al.'s 2019 study, women's vaginal health is a crucial aspect of active and healthy aging in midlife and beyond. Their study's goal was to explain the significance of vulvovaginal atrophy prevalence for healthy aging in women. The occurrence of VVA, which was diagnosed clinically in the study, which included a sample of Italian women seeking a standard gynecological checkup, ranged from 64.7 to 84.2%. Progressive and persistent symptoms play a big role in negative influence on Sexual ability and overall well-being in a large percentage of perimenopausal women. It is evaluated using a subjective grading system (clinician-dependent VHI), cytology-dependent vaginal maturation index, clinical sample, and pH evaluation.

2. Santiago Palacios et al in 2019, conducted a study where they found that vulvovaginal atrophy (VVA) was confirmed in 87.3% of the patients, almost 80% of women who acknowledged being sexually active (n = 717) presented pain during intercourse. Patients with confirmed VVA (n = 1,028) were substantially older, had lower rates of sexual activity, and used more VVA therapies than patients without confirmed VVA (n = 66).

3. According to a 2019 study by Stefania Alvisi et al., the diagnosis of vulvovaginal atrophy, or VOA, is based on clinical assessment, which includes recollection, evaluation of the patient's symptoms, and gynecological examination with evaluation of clinical signs. Additionally, standardized test results and laboratory assessments like the vaginal maturation index (VMI) and pH assessment of the vagina can be used. A significant diagnostic restriction is the lack of constant association between clinical signals (VHI), laboratory results, and symptoms. The diagnosis's subjectivity is still another problem. The vaginal health index (VHI) is one of the most often utilized scores. A precise approach of diagnosis is objective assessment combined with VMI assessment.

4. According to a 2017 study by Michael Krychman et al, postmenopausal women generally failed to recognize VVA and its chronic, progressive process and were reluctant to discuss vaginal or sexual symptoms with their health care professionals (HCPs). This was demonstrated by the women's responses to the EMPOWER survey, which were consistent with those of previous VVA surveys.

5. In a study done in 2016, Rossella E. Nappi et al. discovered that postmenopausal estrogen shortage is the cause of the chronic, age-dependent syndrome known as vulvovaginal atrophy (VVA). VVA is underreported by women, under-recognized by gynecologists, and thus undertreated despite its high prevalence and detrimental impact on quality of life. Women are embarrassed to complain about it, and talking about sexual concerns makes health care workers uncomfortable. Recent studies indicate that when vaginal discomfort is clinically important, health care practitioners should be proactive in encouraging their patients to reveal the symptoms of VVA and seek the appropriate therapy.

6. There is no agreement on the definition and evaluation of vaginal atrophy, M.A. Weber et al. discovered in their study from 2014. They suggested defining VA as a typical sign of estrogen reduction accompanied by certain vaginal symptoms that lower quality of life. VA should be assessed subjectively (using the MBS approach) and objectively (by measuring the vaginal maturation index and the vaginal pH) in both clinical and research contexts.

7. Rachel Hess et al in 2008 found out from their study that sixteen women (80%) preferred self-collection to physician collection, three preferred physician collection, and one chose both. Overall, women found the self-collection to be very easy.

8. According to J. C. Caillouette et al.'s 1997 study, measuring vaginal pH is a valuable, efficient, and affordable screening tool. A premenopausal serum estradiol level and the absence of bacterial infections are both consistent with a vaginal pH of 4.5. A diagnosis of either bacterial infections or low levels of serum estradiol is suggested by an elevated vaginal pH in the range of 5.0 to 6.5.

DISCUSSION:

After going through the reviews it can be stated that –

1. Vulvovaginal atrophy (VVA), despite its great frequency and detrimental effects on quality of life, is rarely reported by women, underdiagnosed by gynecologists, and thus undertreated. This is due to a number of factors. Healthcare providers (HCPs) are generally unaware of all the available treatment choices, and they frequently feel uncomfortable discussing sexual difficulties with patients. Women find it embarrassing to complain about this issue, and HCPs find it awkward as well.

2. There is need in improvement in screening modalities and health care providers (HCP) to be proactive to discuss the issue .The barrier could be avoided by creating a tool which can avoid all these barriers and improve screening though self sampling.

3. Vaginal pH plays important role in perimenopausal women's life. The proposed study is facilitating ph testing does not need speculum examination women can check by herself.

4. Adding a self sampling method by using vaginal atrophy screening (VAS) combistick to the traditional method based vaginal health index (VHI) may have better accuracy while screening vaginal atrophy.

CONCLUSION:

Self-sampling may promote screening participation in under-screened groups by respecting women's privacy. Interventions in education are intended to increase women's health awareness. Self-collected vaginal testing will be less expensive than clinician-collected sampling since, in the majority of low-resource countries, women lack health insurance and frequently pay for their own medical treatment. The vaginal atrophy screening (VAS) combistick will be used to collect two samples from the patients, which will subsequently be forwarded to the pathology lab for evaluation of the hormone level and VMI. Self-sampling can be used in place of other screening programs to avoid vaginal atrophy since it is a significant and prudent act of goodwill. Women can do a number of tasks more efficiently in their personal and social lives, improving their quality of life.

CONFLICT OF INTEREST:

The authors have no conflict of interest.

REFERENCES:

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Received on 30.07.2022 Modified on 26.02.2023

Research J. Pharm. and Tech 2023; 16(12):5663-5666.

DOI: 10.52711/0974-360X.2023.00915