prof. Dr. Sezai ŞAHMAY
İ.Ü. Cerrahpaşa Faculty of Medicine, Department of Obstetrics and Gynecology, Department of
Reproductive Endocrinology
Urogenital atrophy is one of the inevitable problems in the postmenopausal period. In other words, healthy tissues under the influence of estrogen hormones before menopause lose their structure, elasticity, durability and resistance in hormone deficiency. This phenomenon is called urogenital atrophy in medicine . Urogenital atrophy is one of the important health problems that negatively affect the quality of life in these elderly women. Affecting all women in different sizes, urogenital atrophy causes 2 main problems in women. One of them is urinary tract problems (urinary dysfunction), and the other is sexual problems (sexual dysfunction).
Figure-1: In the absence of vaginal tissue estrogen, the integrity and structure of the vaginal tissue loses its normal shape, like dehydrated soil.
Another feature that adds importance to this issue is that although most patients have such complaints, patients (even some doctors) are not aware that this may be related to menopause. For this reason, this situation, which is not usually expressed to the physician by the patient, is easily expressed only when the patient is asked.
The lower part of the female genital and urinary system develops from the same embryological region (urogenital sinus). Due to its structure, this region is under the influence of the hormone estrogen . For this reason, when estrogen decreases, discomfort occurs in this area. This physiological condition, where estrogen decreases and is seen in every woman, occurs after menopause. It is also an important problem in women receiving antiestrogen therapy for breast cancer .
Figure-2: The marked areas in the urogenital region show the areas sensitive to estrogen hormone. When the hormone decreases, complaints begin.
Due to the lack of estrogen, a decrease and thinning of the tissue cells lining the vagina (fertility tract) occurs. In addition, lactobacilli in the vaginal flora decrease and the vaginal pH increases, and the acidic vaginal environment that normally provides vaginal protection against pathogens is disrupted. Lactobacilli are bacteria that make up the natural defense and health of the vagina. This natural defense is disrupted by the decrease of lactobacilli, causing complaints and problems such as itching, tenderness, discharge and stinging in the genital area of the patient.
Again, as a result of decrease and degeneration of connective tissue components such as collagen fibers, elastin and smooth muscle in the vagina, elasticity disappears and turns into a more fragile tissue. As a result, narrowing of the vaginal diameter and shortening of the vaginal length are observed. This is a serious problem that causes discomfort in both vaginal examinations and sexual relations.
Figure-3: Due to the proximity of the vaginal and urinary systems, estrogen deficiency causes both urinary and vaginal complaints.
The most common complaint as a result of vaginal changes caused by hormone deficiency is vaginal dryness . In the postmenopausal period or in cases with estrogen deficiency, a decrease in vaginal blood flow is observed as a result of the decrease in vascularity. As a result of the decrease in vaginal blood supply, vaginal moistening decreases, leading to vaginal dryness. Vaginal dryness is another important factor that causes painful gynecological examination and sexual intercourse .
These changes in the vagina are accompanied by atrophy of the vulva. There is shrinkage and even disappearance (erasing) in labiums (genital lips). While atrophy occurs in the labium majora, the labium minora disappears completely. Vaginal entrance narrows . On the one hand, this narrowing and on the other hand, vaginal dryness are the main causes of pain in intercourse (dyspareunia).
The logic in treatment is quite simple. What is missing is to give the hormone estrogen . This is useful for both urinary tract complaints and genital complaints. This hormone can be in the form of oral tablets, affixed to the hips in the form of a patch, applied to the skin as a gel, or in the form of a vaginal cream or tablet. Since the doses of hormones have been kept very low in recent years, these complaints can be encountered even in those who take hormones orally. Because oral, tape or gel hormone intake must be at higher doses in order to be effective enough to the genital area. Therefore, additional local treatment may be required. Another situation is the situation of those who do not want to take oral hormones or who are inconvenient to take them, in which cases localIt is used as a vaginal ovule, gel or tablet.
Figure-4: Local creams and special vaginal tablets are useful, especially in the treatment of vaginal complaints.
There are studies that show that the local and vaginal use of estrogen does not have a negative effect on the breast.
Another simple solution is the use of lubricants just to facilitate sexual intercourse . This is not treatment, it is the instant prevention of intercourse related complaint.
