Synonyms: urogenital atrophy

Atrophic vaginitis is common in post-menopausal women due to the falling levels of oestrogen.

During the reproductive years, the vaginal epithelium thickens under the influence of oestrogen and produces glycogen. The glycogen-rich cells as they die provide food for Döderlein's bacilli, which in turn produce lactic acid, maintaining an acidic vaginal environment. After the menopause, oestrogen levels fall and this produces changes in the vagina:^1,2

• The vaginal mucosa becomes thinner, drier, less elastic and more fragile. It may become inflamed.
• The vaginal epithelium may become inflamed, contributing to urinary symptoms (below).
• Changes in vaginal pH and vaginal flora may predispose to urinary tract infection (UTI) or vaginal infections.
• Reduced oestrogen levels may affect periurethral tissues and contribute to pelvic laxity and stress incontinence.

Aetiology³

• Natural menopause or oophorectomy.
• Anti-oestrogenic treatments, e.g. tamoxifen, aromatase inhibitors.
• Radiotherapy or chemotherapy.
• Can also occur postpartum or with breast-feeding, due to reduced oestrogen levels.¹

Presentation¹

Symptoms

• There may be no symptoms.⁴
• Dryness, burning or itching of the vagina or vulva.
• Dyspareunia.
• Vaginal discharge (usually white or yellow).
• Vaginal bleeding or post-coital bleeding.
• Urinary symptoms - recurrent UTI, stress incontinence or urgency.

Signs⁵

• External genitalia may show reduced pubic hair, reduced turgor or elasticity, and a narrow introitus.
• Be aware that vaginal examination may be uncomfortable or painful if the patient has atrophic vaginitis.
• Vaginal examination may show:
  • Thin mucosa with diffuse erythema.
  • Occasional petechiae or ecchymoses.
  • Dryness.
  • Lack of vaginal folds.

Investigations

• Investigations may not be necessary if the diagnosis is clear and there are no clinical features causing concern.
• Investigation may be needed to exclude other problems:
  • Any post-menopausal bleeding requires investigation.
  • If there is discharge or bleeding, an infection screen may be relevant (for vaginal infections or endometritis).
  • Other causes of recurrent UTI.
  • Women with unexplained, persistent vaginal discharge need investigation to exclude gynaecological neoplasms.⁶
  • Screen for diabetes (uncontrolled diabetes can contribute to symptoms).
• Other possible investigations are:^1,5
  • Vaginal pH testing (using pH paper and sampling from the mid-vagina, not the posterior fornix). The result is more alkaline in atrophic vaginitis.
  • Vaginal cytology - can show lack of maturation of the vaginal epithelium, typical of atrophic vaginitis.

Differential diagnosis⁶

• Genital infections, e.g. bacterial vaginosis, trichomonas, candidiasis, endometritis:
  • These may co-exist, as atrophic vaginitis predisposes the vagina to bacterial infection.¹
  • Trichomonas and bacterial vaginosis also give a more alkaline result on pH testing (pH>4.5)⁷
• Other causes of vaginal bleeding or post-menopausal bleeding.
• Uncontrolled diabetes may cause vaginal or urinary symptoms.
• Local irritation due to: soap, panty liners, spermicides, condoms, biological washing powder and tight-fitting clothes.

Management

Vaginal symptoms

Management options are:

• Vaginal moisturisers - can be bought over-the-counter.
• Hormone replacement therapy (HRT):
  • This may be topical HRT or systemic.
  • With topical HRT - creams, pessaries, tablets and the estradiol vaginal ring all seem to be effective.⁸ See separate article Topical HRT.
  • Topical HRT seems to be more effective than systemic therapy.⁹

Urinary symptoms

• HRT may help in some situations:
  • A Cochrane review of HRT for incontinence found that:¹⁰
    • Oestrogen treatment can improve or cure incontinence; this is more likely with urge incontinence. There were insufficient data to comment on oestrogen type, dose and route of administration. Also there was no information as to the outcomes after oestrogen is stopped.
    • Combined oestrogen and progesterone may make the incontinence worse.
  • The Royal College of Obstetricians and Gynaecologists (RCOG) study group suggested that:⁹
    • Irritative urinary symptoms (urgency, etc.) may be helped by oestrogens.
    • Stress incontinence cannot be treated effectively by oestrogens alone, although oestrogen may be an adjunct to surgery.
    • Topical HRT may reduce recurrent urinary tract infections, and can be used for this indication once other pathology has been excluded.
• There are other treatments for urinary incontinence, e.g. bladder training, pelvic floor exercises and alpha-agonists.

Prognosis

Symptoms may return on cessation of treatment.¹¹

Document references

1. Bachmann,GA and Nevadunsky,NS; American Family Physician: May 15,2000; Diagnosis and treatment of atrophic vaginitis
2. Castelo-Branco C, Cancelo MJ, Villero J, et al; Management of post-menopausal vaginal atrophy and atrophic vaginitis. Maturitas. 2005 Nov 15;52 Suppl 1:S46-52. Epub 2005 Sep 1. [abstract]
3. Beard MK; Atrophic vaginitis. Can it be prevented as well as treated? Postgrad Med. 1992 May 1;91(6):257-60. [abstract]
4. Davila GW, Singh A, Karapanagiotou I, et al; Are women with urogenital atrophy symptomatic? Am J Obstet Gynecol. 2003 Feb;188(2):382-8. [abstract]
5. Leber MJ, Tirumani A. Vulvovaginits. emedicine, August 2009.
6. Mitchell,H; ABC of sexually transmitted diseases: Vaginal discharge - causes,diagnosis and treatment; BMJ 2004;328:1306-1308
7. Sexually Transmitted Infections in Primary Care, Royal College of General Practitioners (2006)
8. Suckling J, Lethaby A, Kennedy R; Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD001500. [abstract]
9. RCOG. Menopause and Hormone Replacement - study group statement. December 2004.
10. Moehrer B, Hextall A, Jackson S; Oestrogens for urinary incontinence in women. Cochrane Database Syst Rev. 2003;(2):CD001405. [abstract]
11. Urogenital atrophy, British Menpause Society Censensus Statement (May 2008)

Internet and further reading

• Pitkin J, Rees M; Urogenital atrophy. Menopause Int. 2008 Sep;14(3):136-7. [abstract]
• Women’s Health Concern. A charity providing information for women about their health concerns.

Acknowledgements