Chapter 34 Atrophic and dystrophic conditions
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.
The vagina
The changes in the vagina depend on levels of oestrogen, which continues to be synthesized in peripheral tissues, but in most women the vaginal epithelium becomes atrophic. The superficial cells diminish in number, and intermediate and parabasal cells predominate. These changes show clinically as vaginal discomfort and burning, and painful intercourse.
The pelvic floor
Deprived of oestrogen, the blood supply to the muscles of the pelvic floor diminishes. The pelvic floor muscles lose their tone and the connective tissue loses its elasticity, with the result that pelvic floor tissues damaged during childbirth are likely to relax, with varying degrees of prolapse (see Ch. 38).
The vulva
As a woman’s age increases, the labia majora lose their fat and elastic tissue content and become smaller, and the vaginal introitus is exposed. In very old women, only a narrow cleft indicates the presence of the vaginal introitus.
The vulval epithelium becomes thin, with loss of elastic and collagen fibres. These changes may lead to vulval irritation, although this may occur at earlier ages.
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
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