Gupta AS
Merriam- Webster dictionary defines 'atresia' as the absence
or closure of a natural passage of the body. Vaginal atresia can be congenital
or acquired. Congenital occurs from birth though it is usually diagnosed after
puberty. Acquired occurs in an adult woman who has previously menstruated or
even borne children.
Acquired atresia may involve the entire length of the vagina
or may be partial. Closure of the previously patent vagina may occur at its
introital end, some distance beyond the introitus or at the upper end near the
fornices though usually the presence of the cervix prevents a complete
obliteration of the upper end of the vagina. The vaginal normally remains in
the closed state with its anterior and the posterior wall apposed to each other
mainly in its middle and the lower segment.
Vaginal is lined by squamous epithelium which matures and
thickens under the influence of estrogens. It becomes rich in glycogen.
Doderleins bacilli produce lactic acid in the vagina. This lowers the vaginal
pH. The thick vaginal epithelium and the acidic pH are the defence mechanisms
of the vagina. Vaginal mucosa is thin in the prepubertal and in the post
menopausal women. In lactating women also there may be a relative deficiency of
the estrogen hormone making the vagina thin and less acidic. Some women on
antiestrogens like GnRh antagonists, SERMS without hormonal 'add-back' also
develop estrogen deficiency. Women receiving radiotherapy, chemotherapy, or who
have undergone oophorectomy also have estrogen deficiency. Estrogen deficiency
is known to result in cytological changes in the vagina. Fragmentation of
elastin, proliferation of its connective tissue and hyalinization of its
collagen fibers are all well documented. These changes at the cellular level
results in injury to the epithelium, abrasions, granulation tissue formation,
erosions and ulcerations. While the woman leads a physically active sexual life
the vaginal patency is maintained but in estrogen deficient women who are
sexually inactive the vaginal walls remain apposed to each other. Presence of
inflammation, erosions or granulation tissue in the vagina epithelium then
predisposes to adhesion formation and when these are dense then the vagina gets
obliterated. In some cultures women after childbirth stay away from their
spouse and the resumption of sexual activity is delayed. Dyspareunia is the
usual presenting symptoms in such patients. They then seek medical aid.
Sometimes a pin hole opening may remain and this permits the menstrual flow
whenever menstruation resumes like that in a lactating woman. Diagnosis can be
made on clinical examination with the use of a speculum or a gloved finger. If
the lower part of the vagina is obliterated separation of the labia may show
the completely or partially closed introitus. Attempt to insert a speculum or a
digit will result in pain and the tissues will feel firm and rigid. Shortening
of the vagina can also be diagnosed when the upper part of the vagina is
obliterated. Treatment can be combined medical, surgical and life style
adaptation. In case of dense peri introital adhesions estrogen replacement in
the form of local creams or oral supplementation can be attempted. However,
with dense adhesions surgical approach may also be required as seen in the case
report by Dr. Sarogi M.R. However, in their patient they have not tried the use
of estrogen creams. After surgical correction the patient should use estrogen
for healing and resume an active sexual lofe or use vaginal dilators to prevent
the recurrence of vaginal atresia. Encouraging these women to continue active
sexual life is a very important life style modification especially in post
menopausal women where long term estrogen deficiency exists.
I present the July issue of
our journal and hope our esteemed readers gain useful insight of the various
clinical cases.