3. Atrophic Vaginitis

Atrophic Vaginitis

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

Synonyms: urogenital atrophy

Atrophic vaginitis is very common in postmenopausal women due to the falling levels of oestrogen.

During the reproductive years, the vaginal epithelium thickens under the influence of oestrogen and produces glycogen. As they die, the glycogen-rich cells 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:

  • 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 (see under  'Presentation', 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.
  • Natural menopause or oophorectomy.
  • Anti-oestrogenic treatments - eg, tamoxifen, aromatase inhibitors.
  • Radiotherapy or chemotherapy.
  • It can also occur postpartum or with breast-feeding, due to reduced oestrogen levels.

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It has been estimated that 4-5 years after the menopause, around 25-50% of women experience symptoms due to atophic vaginitis. However, only around 24% of these women with symptoms actually seek medical help.[1] 

It is important to initiate discussion regarding any vaginal dryness with postmenopausal women, as many women are very reluctant to talk about it or initiate conversation about it.

Symptoms

  • There may be no symptoms.
  • Dryness of the vagina is the most common symptom.
  • There may be burning or itching of the vagina or vulva.
  • Dyspareunia.
  • Vaginal discharge (usually white or yellow).
  • Vaginal bleeding or postcoital bleeding.
  • Urinary symptoms - eg, increased frequency, nocturia, dysuria, recurrent UTI, stress incontinence or urgency.

Signs

  • 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 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.
    • Screen for diabetes (uncontrolled diabetes can contribute to symptoms).
  • Other possible investigations are:
    • 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.
  • Genital infections - eg, bacterial vaginosis, trichomonas, candidiasis, endometritis:
    • These may co-exist, as atrophic vaginitis predisposes the vagina to bacterial infection.
    • Trichomonas and bacterial vaginosis also give a more alkaline result on pH testing (pH>4.5).
  • Other causes of vaginal bleeding or postmenopausal 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.

Treatments are often underused because of patient and clinician lack of knowledge of available treatments, embarrassment about initiating a discussion of symptoms and reluctance to initiate hormonal therapy.[2] 

Current treatment guidelines for vaginal atrophy recommend the use of minimally absorbed local vaginal oestrogens, along with non-hormonal lubricants or moisturisers, coupled with maintenance of sexual activity.[3] 

The principals of management are:

  • Restoration of urogenital physiology
  • Alleviation of symptoms

Non-hormonal treatments

Lubricants:

  • These provide short-term relief.
  • They can improve dryness during intercourse.
  • Replens MD® and Sylk® are acidic, non-hormonal vaginal moisturisers.

Moisturisers:

  • These are bio-adhesive so attach to mucin and epithelial cells on the vaginal wall so therefore retain water.
  • They can also lower vaginal pH.
  • Numerous preparations are available over-the-counter.
  • NB: Vaseline® can break down the latex in condoms so is not recommended for women whose partners are using condoms.

The efficacy of lubricants and moisturisers is generally thought to be lower than that with using topical oestrogens, although some experts believe that when they are applied on a regular basis then they have an efficacy comparable with that of local oestrogen therapy.[4] 

Phyto-oestrogenic preparations:

  • These include red clover isoflavones.
  • There is some evidence to show they can be beneficial.
  • However, there are no data regarding their safety so they are not recommended.

Hormonal treatments

Topical and systemic oestrogens are the most efficacious treatments for atrophic vaginitis.

Hormone replacement therapy (HRT):

  • Restores the vaginal pH.
  • Works by thickening and revascularising the vaginal epithelium, so improving lubrication.
  • Also helps to improve urinary symptoms.
  • Systemic HRT is not usually recommended for those women with only vaginal symptoms and no menopausal symptoms.[5] 
  • Around 10-25% of women still have symptoms and so will require topical oestrogen in addition to HRT.

Topical treatments (refer to HRT - Topical for further information):

  • There are various preparations available, including rings, vaginal tablets, pessaries and creams.
  • It is common to have more vaginal discharge with pessaries and creams. This may be an advantageous side-effect in sexually active women.
  • A Cochrane review found that women appeared to favour the estradiol-releasing vaginal ring for ease of use, comfort of product and overall satisfaction.[6] 
  • Individual preference is important when deciding on which type of topical treatment to prescribe.[7]
  • Topical vaginal oestrogen preparations reverse urogenital atrophic changes and may relieve associated urinary symptoms.[8]
  • There is no evidence that topical oestrogen causes endometrial proliferation after 6-24 months of use.
  • Low-dose topical oestrogen does not therefore need to be given with systemic progestogens.[9]
  • Although there is still a lack of long-term data for the use of long-term oestrogen over six months, long-term low-dose topical oestrogen is not contra-indicated.

Most women will have relief from their symptoms after about three weeks of treatment. Maximal benefit usually occurs after 1-3 months but may take up to a year.

Women receiving hormonal treatment should all be advised to contact their doctor if they experience any vaginal bleeding.

If symptoms have not improved with hormonal treatment, then another underlying cause of the symptoms should be considered (eg, dermatitis, vulvodynia).

Prognosis

Symptoms are likely to return on cessation of treatment.

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Further reading & references

  1. Sturdee DW, Panay N; Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010 Dec;13(6):509-22. doi: 10.3109/13697137.2010.522875. Epub 2010 Sep 30.
  2. Woods NF; An overview of chronic vaginal atrophy and options for symptom management. Nurs Womens Health. 2012 Dec;16(6):482-93; quiz 494. doi: 10.1111/j.1751-486X.2012.01776.x.
  3. Krychman ML; Vaginal estrogens for the treatment of dyspareunia. J Sex Med. 2011 Mar;8(3):666-74. doi: 10.1111/j.1743-6109.2010.02114.x. Epub 2010 Nov 22.
  4. Tan O, Bradshaw K, Carr BR; Management of vulvovaginal atrophy-related sexual dysfunction in postmenopausal women: an up-to-date review. Menopause. 2012 Jan;19(1):109-17. doi: 10.1097/gme.0b013e31821f92df.
  5. Goldstein I; Recognizing and treating urogenital atrophy in postmenopausal women. J Womens Health (Larchmt). 2010 Mar;19(3):425-32. doi: 10.1089/jwh.2009.1384.
  6. Suckling J, Lethaby A, Kennedy R; Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD001500.
  7. Archer DF; Efficacy and tolerability of local estrogen therapy for urogenital atrophy. Menopause. 2010 Jan-Feb;17(1):194-203. doi: 10.1097/gme.0b013e3181a95581.
  8. Ewies AA, Alfhaily F; Topical vaginal estrogen therapy in managing postmenopausal urinary symptoms: a reality or a gimmick? Climacteric. 2010 Oct;13(5):405-18. doi: 10.3109/13697137.2010.500748.
  9. Al-Baghdadi O, Ewies AA; Topical estrogen therapy in the management of postmenopausal vaginal atrophy: an up-to-date overview. Climacteric. 2009 Apr;12(2):91-105. doi: 10.1080/13697130802585576.
Original Author: Prof Cathy Jackson Current Version: Peer Reviewer: Prof Cathy Jackson
Last Checked: 10/05/2013 Document ID: 453  Version: 3 © EMIS

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.