ATROFIČNI VAGINITIS Mahira Jahić Definicija Etiologija Klinička slika Dijagnoza Diferencijalna dijagnoza Terapija...
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1 ATROFIČNI VAGINITIS Mahira Jahić Definicija Etiologija Klinička slika Dijagnoza Diferencijalna dijagnoza Terapija...178
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3 Atrofični Vaginitis Definicija Atro ični vaginitis je upalna promjena zida vagine nastala zbog snižene količine estrogena i smanjene funkcije jajnika. Etiologija Manjak estrogena u postmenopauzalnih žena je značajan faktor nastanka strukturnih i funkcionalnih promjena u svim anatomskim slojevima vagine, uretre i mokraćne bešike što se klinički pokazuje sa nizom simptoma kao što su vaginalna suhoća, pečenje, dispareunija, učestalo dnevno i noćno mokrenje, recidivirajuće uroinfekcije i inkontinencije urina. Preko 40% žena u postmenopauzi ima neke od znakova atro ičnog vaginitisa. Vaginalna atro ija nastaje kod svih žena u menopauzi kada ponestane estrogena, ali to ne znači da sve žene sa vaginalnom atro ijom imaju atro ični vaginitis (Slika 77.). Koncentracija estrogena u perimenopauzalnih žena je u prosjeku 120 ng/ml i poslije menopauze počinje da se snižava do oko 19 ng/ml. Hormon koji do- Smanjena produkcija estrogena Porast ostalih bakterija Smanjena produkcija glikogena Mehanizam nastanka vulvovaginalne atro je Povećanje ph vrijednosti vaginalne sekrecije Smanjena produkcija mliječne kiseline Smanjena eksfolijacija vaginalnih ćelija Stanjena pločastog epitela Smanjena broja laktobacila Slika 77. Mehanizam nastanka vaginalne atrofije
4 VAGINITISI Vaginalni epitel u menopauzi Pre-Menopause Post Menopause Super cijalne ćelije 15% 1% Intermedijalne ćelije 80% 60% Parabazalne ćelije 5% 39% Menopause minira kod ovih žena je androstendion koji se pretvara u perifernom masnom tkivu u estrogen. Testosteron proizvode ovarijumi i može da se pretvari u estradiol. Čim se endogeno nadoknadi estrogen postmenopauzalni ovarijumi normalno funkcionišu. Smanjenje estrogena se odražava na vaginalni površni epitel koji gubi elasticitet, nabore, debljinu i postaje tanak i ravan (Slika 78.). Vaginalni epitel koji je izgubio elasticitet i rastezljivost postaje kraći i uži. Te promjene epitela izazivaju kod žena u postmenopauzi dispareuniju koja je uzrok izbjegavanja seksualnih odnosa. Smanjenje ili nedostatak nivoa estrogena uzrokuje promjene koje su prilično vidljive na vaginalnom epitelu. Nalazi se također nedostatak zrelih i navikularnih epitelnih ćelija, a signi ikantno povećanje intermedijernih i parabazalnih ćelija. Fiziološke promjene u vaginalnom ekosistemu postmenopauzalnih žena su prilično vidljive kao smanjenje glikogena, smanjenje karbohidrata što za rezultat ima smanjenje porasta laktobacila. Ova promjena rezultira smanjenjem Slika 78. Promjene epitela u postmenopauzi kiselosti vaginalne sredine i povećanjem ph vrijednosti na 5. Vaginalna sekrecija mjenja boju iz bijele u prljavo sivu jer nema porasta laktobacila pa mogu rasti drugi mikroorganizmi i broj leukocita se povećava. Ukoliko se dese promjene u vaginalnoj sekreciji u smislu porasta drugih mikroorganizama status iz vaginalne atro ije mjenja se u atro ični vaginitis. Klinička slika Pacijentice veoma često imaju vaginalnu atro iju, a da to i ne znaju. Veliki broj žena koje imaju seksualne odnose žale se na suhoću vagine. Zato što je vagina skraćena i nema nabore pacijentice osjete bolove i nelagodu. Radi ovih simptoma one često odbacuju seksualne odnose. U takvim situacijama pacijenti su primorani tražiti pomoć od doktora. Pojavljivanje vaginalnog krvarenja, obilne vaginalne sekrecije i vaginalnog crvenila su znakovi koji pacijenticu obavezno dovode ljekaru.
5 Atrofični Vaginitis Promjene i simptomi koji se često nađu kod atro ičnog vaginitisa: 1. Skraćenje i suženje vagine, 2. krvarenje vezano za odnos, 3. razvoj uretralnog karbunkula, 4. otežano mokrenje, 5. crvenilo vulve, 6. svrab vulve, 7. bolni i neprijatni odnosi, 8. vodena sekrecija. Slika 79. Atrofični vaginitis Tabela 15. Dijagnoza atro ičnog vaginitisa Laboratorijska dijagnoza atro ičnog vaginitisa Dijagnoza Dijagnoza atro ičnog vaginitisa se postavlja ginekološkim pregledom, laboratorijskom analizom hormona, određivanjem vrijednost ph vagine i mikroskopskom analizom vaginalne sekrecije (Tabela 15.). Ginekološkim pregledom se može uočiti sljedeće: 1. Vaginalni epitel je blijed i sa pete hijalnim krvarenjima (Slika 79.), Pozitivni znaci Vaginalni bris i citološki pregled ćelija Ultrazvučni pregled Atro ične citološke promjene uključujući povećanje parabazalnih ćelija Pregled uterusa pokazuje debljinu endometrijuma ispod 5 mm Koncentracija hormona u serumu Nizak nivo estrogena <4,5 Vaginalna ph Mikroskopski pregled ph elevacija iznad normalepostmenopauzalna ph Eliminacija trichomonijaze, kandidijaze i bakterijske vaginoze
6 VAGINITISI Slika 80. Izgled ćelija u postmenopauzi na PAPA testu (atrofija) 2. crvenilo i zažarenost vagine, 3. vaginalni zidovi su glatki a nabori prorijeđeni, 4. pukotine epitela na malim usnama, zadnjem zidu vagine i vestibulumu, 5. sinehije između vaginalnih zidova. Pacijentice sa vaginalnom atro ijom nerijetko imaju infekciju urinarnog sistema, te problem sa urinarnom inkontinencijom. Laboratorijska dijagnostika uključuje analizu hormona u serumu i PAPA test koji pokazuje postojanje urogenitalne atro ije (Slika 80.). U brisu vaginalnog zida nalazi se povećan broj parabazalnih ćelija i smanjenje super icijalnih ćelija. Diferencijalna dijagnoza Najčešća oboljenja sa sličnim simptomima i tegobama su: 1. Kandidijaza 2. Bakterijska vaginoza 3. Trihomijaza 4. Kontakna iritacija i reakcija na: parfeme, pudere, dezodoranse, sapune, spermicide i lubrikante. 5. Subkoitalne povrede Terapija Za liječenje vaginalne atro ije i atro ičnog vaginitisa potrebna je prije svega nadoknada estrogena oralno ili vaginalno. Ako je upala izražena bolje je odlučiti se za oralnu terapiju estrogenima, dok je vaginalna adekvatnija za preventivne svrhe. U terapiji atro ičnog vaginitisa se koriste sljedeći estrogenski preparati: 1. Estradiol vaginalne tablete 10 i 25 mg. 2. Estrogen vaginalete 25 mg 3. Transdermalni estrogeni laster 12,5 µg tokom 24 sata 4. Estrogen u obliku vaginalnog pesara 25µg Lokalno liječenje estrogenima pokazalo se uspješnim kod žena sa urogeni-
7 Osnove razvoja i anatomije ženskih polnih organa Slika 81. Promjene u vaginalnom epitelu kod atrofičnog vaginitisa talnom atro ijom i simptomima disurije, jer estrogeni povećavaju uretralni otpor. Lokalni estrogeni smanjuju broj infekcija žena u postmenopauzi sa ponavljajućim infekcijama mokraćnih puteva i zato su važan dio liječenja.
8 VAGINITISI LITERATURA 1. Cardozo L, Bachmann G, McClish D, Fonda D, Birgerson L. Meta-analisis of estrogen therapy in the menagmenturogenital atrophy in post-menopausal women: second report of the Hormones and Urogenital Therapy Committee. Obst Gynecol. 1998;92: Chou CP, Leverson R, Elsayes K. Imaging of female urethral diverticulum:an update Radiographics. 2008;28: Greendale G, Judd H of. The menopause: helth implications and clinical menagment. J Am Geriatr Soc. 1993; 41: Pandit L, Ouslander J. Postmenopausal vaginal atrophy and atrophyc vaginitis. Am J Med Sci. 1997;314: Raz R, Stamm WE. A control trial of intravaginal estriol in postmenopausal women with recurrent urinary infections. N Engl J Med 1993;320: Tseng LH, Wang AC, Chang YL. Randomised comparsion of tolterodine with vaginal estrogen cream versus tolterodine alone for tretment of postmenopausal women with overactive bladder syndrome. Neurourol Urodynam 2009; 28:47-51.
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