INTRODUCTION: A wide number of methods to evaluate vulvovaginal atrophy (VVA) as part of genitourinary syndrome of menopause (GSM) have been studied and used clinically yet lack standardization. Numerous studies have evaluated individual methods, but there is limited evaluation that uses histological techniques, and further limited work combining clinical objective and subjective analysis with histological assessment. OBJECTIVE: We sought to evaluate VVA using clinical and histological methods in order to develop a standardized method of atrophy evaluation and to assess if clinical factors can predict histological changes seen in menopause. METHODS: A prospective cohort discovery study of women (>18 years) undergoing hysterectomy and/or pelvic organ prolapse surgery was performed, with exclusion of those with prior pelvic radiation, current vaginal mesh in situ, class III or IV obesity, or recent treatment with androgens or gonadotropin-related medications. Twenty-four participants were included. Subjects were included even if using vaginal estrogen therapy or hormone replacement therapy. Symptom questionnaires, including the Vulvovaginal Symptom Questionnaire (VSQ), Urinary Distress Inventory Short Form (UDI-6), and Menopause Rating Scale (MRS), were administered preoperatively. Physical exam scores using the Vaginal Health Index (VHI) and Vaginal Atrophy Index (VAI) (10–13), vaginal pH, and vaginal maturation index (VMI) samples were collected prior to surgery. A uniform anterior apical full-thickness vaginal wall sample was collected intraoperatively and stained with hematoxylin and eosin staining for histological evaluation. Histological evaluation and VMI analysis were performed by two independent, blinded pathologists. Participants were categorized into two groups based on age for analysis: early post-menopausal (52–64, or age of menopause diagnosis if <52) or late post-menopausal (≥65). RESULTS: No significant differences in clinical evaluation scores were seen between early- and late-menopause subjects, except for more severe symptom scores on the MRS psychological subscale in the early- versus late-menopause group (6.1 vs 1.5, p=0.0142). No significant differences in clinical evaluation scores were seen between post-menopausal (early and late groups combined) on vaginal estrogen therapy versus those who were not. Strong correlation between clinical evaluation methods was seen on bivariate analysis using Pearson’s coefficient (pH and VMI, r=−0.62, p=1.65–5; pH and VHI, r=−.72, p=1.91–7; pH and VAI, r=0.53, p=0.000039; VMI and VHI, r=0.73, p=1.04–7; VMI and VAI, r=−0.73, p=8.11–8; VHI and VAI, r=−0.91, p=2.3–16). There was no significant difference in epithelial thickness or rete ridge height on histological analysis between post-menopausal subjects on estrogen therapy versus those not on therapy. Epithelial thickness and rete ridge height were not correlated with clinical findings on bivariate analysis using Pearson’s coefficient. Multivariate regression analysis did not find that clinical measures of VVA were able to predict epithelial thickness (R2=0.14, p=0.37). CONCLUSIONS: Clinical findings in VVA do not appear to be predictive of histological findings in menopausal women with or without significant symptoms of GSM. Our data is limited due to the non-powered sample size in this discovery study. More research is needed to validate our findings to make conclusions on the best evaluation methods of VVA as part of GSM.Table 1
Degraffenreid et al. (Fri,) studied this question.