Genitourinary atrophy Part II: talk to your midwife or gynecologist

Therapies for genitourinary atrophy aim to recover urogenital physiology, prevent genitourinary infections and improve symptoms such as dryness, itching, burning and dyspareunia.

For this, it is necessary that the altered parameters by hypoestrogenism return to normal (pH, physiological flora, lubrication and trophism).

Possible available therapeutic routes are: lubricating and moisturizing therapies, local phytoestrogenic preparations, hormone replacement therapy, local estrogen therapy, oral intake of tibolone or ospemifene, treatment with vaginal CO2 laser, biostimulation or filler (monphasic hyaluronic acid), electroporation-radio frequency.

Let’s see them all together:

• In case of vaginal atrophy, it may be useful to use non-hormonal lubricants with water, oil or hyaluronic acid, vitamin A, E, colostrum and phytotherapeutic principles that have moisturizing properties and stimulate vaginal trophism.

These active ingredients are very useful as they relieve vaginal dryness and facilitate sexual intercourses. However, their use is not therapeutic, but has only palliative purpose, although in clinical practice it has been observed that constant use can bring lasting benefits.

These preparations can be found in the form of gels, creams or vaginal ovules.

Good lubrication is essential during sex too; on the market there are natural creams that, in addition to contain useful moisturizing active ingredients, nourish and soothe skin and mucous membranes.

Also D-Mannose helps to restore the integrity of mucous membranes and prevent bacteria from adhering to them.

• Phytoestrogens are substances of vegetable nature (not steroidal) capable of binding to estrogen receptors.

These substances have a similar action to hormones: by binding to estrogenic receptors, they trigger all the processes regulated by these hormones, although with lesser effects. They also have non-hormonal, antioxidant and anti-inflammatory action.

The main natural sources are soy and red clover. Isoflavones are the family of phytoestrogens that have the highest estrogenic activity and affinity, interacting with estrogen receptors distributed throughout the body.

There are formulations based on phytoestrogens for topical use with emollient, soothing, moisturizing and lubricating activity. They are useful to relieve symptoms of dryness, itching and burning. They improve sexual intercourses, rebalance vaginal pH and vaginal flora.

• The first level therapy for menopausal genitourinary atrophy is the topical administration of estrogens. The efficacy and safety of local vaginal estrogen therapy is now demonstrated by numerous clinical studies. It is based on the use of conjugated equine estrogens such as estradiol, estriol or estrone, administered in the form of vaginal tablets, ovules, creams or vaginal rings.

• Hormone replacement therapy for urogenital disorders is based on the effect that estrogens have on the urogenital tract. Numerous studies have demonstrated the effectiveness of hormone replacement therapy in the treatment of genitourinary atrophy.

Estrogens increase the trophism of vaginal, urethral and bladder epithelium. They also increase the pressure of the urethral closure (thus preventing the loss of urine) and the sensitivity threshold of the bladder, with an improvement of urination neuronal control (improvement of urinary frequency and urgency). However, the effect is limited only to the treatment period and stop at the end of it.

• Tibolone is a synthetic steroid classified as selective modulator of estrogenic activity since it acts differently on several target tissues and organs. The medicine exerts estrogenic, progestin and weakly androgenic action. Good results on vaginal dryness and libido were obtained, improving symptoms related to sexual dysfunction.

• Another possibility is the use of a selective estrogen receptor modulator: the ospemifene. It is a non-hormonal cure administered orally. This medication is well tolerated and effectively promotes trophism of the vaginal mucosa with minimal impact on the endometrium.

• A new frontier has been opened in the treatment of postmenopausal problems of the female genital tract, following the introduction of fractional CO2 laser technology (the best known is Monnalisa Touch) and the creation of instruments dedicated to the vulvo-vaginal sphere.

The laser acts directly on the vulvar and vaginal mucosa to stimulate the metabolic reactivation of the fibroblasts, obtaining a tissue regeneration. The application of the CO2 laser on the vaginal walls is done through a probe that guarantees a homogeneous distribution of the impulse in the vaginal walls. This reactivates the synthesis of extracellular matrix and collagen that leads to the recovery of tissue tropism.

The improvement of mucosal trophism leads to an increase in cellular glycogen. It favors the recolonization by lactobacilli and a restoration of vaginal acidity. The results appear after a month and a half after the first session. The treatment is minimally invasive, does not require anesthesia and can be done in a clinic with rare or mild and transient side effects.

• There are outpatient operations that involve the injection of monophasic hyaluronic acid. A session lasts about 20-30 minutes. The effect lasts 12-18 months and sessions can be repeated as necessary. To improve trophism and skin elasticity, infiltrations with biostimulants or biorevitalizers can also be performed.

• Radiofrequency and electroporation (known as Vagy Combi) is a non-invasive and completely painless procedure.

It is based on the use of two methods, electroporation and radiofrequency, which can be used together or separately to improve therapeutic performance. Radio frequency is a non-invasive and painless practice: through external and internal applicators capable of inducing an increase in temperature, it restores the energy potential of cell membranes, stimulating the production of collagen and increasing the contractile efficiency of the muscles. It ensures the regenerative effects in the affected area since the first treatments.

Electroporation is a non-invasive and painless technology that can be defined as a “virtual syringe.” A particular electromagnetic impulse causes an active principle to be absorbed without needles transdermally, ensuring greater concentration and effectiveness only in the envolved areas.

In addition to the therapeutic pathways listed above, pelvic floor rehabilitation can be very useful. Perineal exercises help to improve local vascularization and allow to better control the perineal muscles and keep them more relaxed during intercourse. All this avoids the vicious circle of contracture, dyspareunia, postcoital cystitis and additional contraction.

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