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.