Atrophic and dystrophic conditions

Published on 10/03/2015 by admin

Last modified 22/04/2025

Print this page

This article have been viewed 2098 times

Chapter 34 Atrophic and dystrophic conditions

In the years after the menopause the internal genital organs become smaller and atrophic. These changes occur because the amount of circulating oestrogen falls to a very low level.

ATROPHIC CHANGES OF THE INTERNAL GENITAL ORGANS

Vulval atrophy in older women

By the time a woman reaches the age of 75 the uterus, the Fallopian tubes and the ovaries have shrunk considerably (Fig. 34.1). In the uterus, the endometrium has become atrophic and the muscle fibres of the myometrium have been progressively replaced by fibrous tissue. The cervix has atrophied and the cervical canal may become obliterated. If the woman develops uterine infection the pus might not escape, leading to a pyometra. This may also occur if the woman develops an endometrial or cervical carcinoma. The woman may complain of lower abdominal pain, and an examination shows that the uterus is larger than expected for her age. The diagnosis is confirmed by ultrasound scanning, which shows that the uterine cavity is enlarged and filled with fluid. If carcinoma is detected it is treated appropriately; if it is not present, the cervix is dilated and a drain inserted for a few days.

Fig. 34.1 Reduction in the size of the uterus in old age.

Vulval atrophy in younger women

Vulval atrophy may occur in a few younger women. It can cause considerable distress, not only because it is uncomfortable but because it prevents sexual intercourse, or makes it painful. The woman should be investigated for the presence of impaired glucose tolerance, and allergic conditions sought. Treatment is not very effective. The woman should be advised not to wear pantyhose, as these garments prevent ventilation and increase vulval moisture. Most medications are ineffective.

PRURITUS VULVAE (ITCHY VULVA)

One woman in 10 who attends a medical practitioner for genital tract disorders will say, among other complaints, that she has an itchy vulva. The reason may be infection, general skin or medical disease, or emotional problems. Emotional problems are thought to cause vulval itch in some women because both the skin covering the vulva, and its underlying capillaries, are unstable. Thus sexual or marital problems, anxiety and depression may manifest somatically as vulval itch.

Whatever the cause, the itch, mediated by a release of histamines, leads to scratching, which aggravates the itch. Over a period of months, the itch–scratch cycle may initiate a variety of histological changes in the vulval skin – non-neoplastic epithelial disorders of the skin and mucosa.

There have been a number of attempts to classify the disorders of the vulval epithelium. The most recent is shown in Box 34.1.

The most common vulval problem is lichen sclerosis, which presents with chronic pruritus, pain and dyspareunia if there is ulceration and fissures. The skin may be reddish or normal in colour, and atrophic shiny white plaques are seen. A skin biopsy shows that the horny layer is unchanged or hyperkeratinized, with thinning of the epidermis and the disappearance of the rete pegs. The dermis is oedematous, with some degree of hyalinization, and collections of round cells are seen (Fig. 34.2).

Fig. 34.2 Lichen sclerosis (atrophic pattern).

Biopsy of the affected areas is indicated if there is any doubt about the diagnosis and/or malignancy or premalignancy is suspected. Treatment is with topical corticosteroids, the most effective being clobetasol propionate applied nightly for 4 weeks, alternate nights required. The woman should be encouraged to use a soap substitute. Topical testosterone has been shown to be no more effective than emollients.

Squamous hyperplasia

The skin is usually reddened with exaggerated folds. In certain areas lichenified white patches may be seen. A biopsy specimen will show a thickened epithelium, with elongated papillae which retain their normal shape. The dermis is oedematous and contains numbers of plasma cells (Fig. 34.3).

Fig. 34.3 Squamous hyperplasia.

Vulval intraepithelial neoplasia (VIN) is discussed in Chapter 37.

Aetiology

Studies of women who have pruritus show that this disease has a varied aetiology.

General skin diseases

The conditions listed in Table 34.1 are the usual skin diseases that may manifest as pruritus vulvae. Fungal infections may also cause vulval itch, although the itch is generally intercrural.

Table 34.1 The itchy vulva: aetiology

	Percentage of Cases
General skin diseases (psoriasis, leucoderma, lichen planus, intertrigo, scabies)	5
General diseases (diabetes, ? deficiency diseases)	5
Allergic dermatitis	5
Vaginal discharges Trichomoniasis Candidiasis	50
Psychosomatic conditions	35