Atrophic Vaginitis

Atrophic vaginitis describes a condition which is 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. The glycogen rich cells as they die provide food for Döderleins bacilli, which in turn produce lactic acid, maintaining an acidic vaginal environment. After the menopause, with the decline in oestrogen and glycogen levels, the pH of the vagina rises and there is a proliferation of connective tissue, hyalinization of collagen and fragmentation of elastin¹, with thinning of the epithelium; which may result in infections, fissures and ulceration.²

• Approximately 40% of women in the postmenopausal years will experience some of the symptoms of atrophic vaginitis, however it is thought that only 20-25% of these will seek medical attention.³
• Atrophic vaginitis may also occur in pre-menopausal women who are taking anti-oestrogenic treatments such as Tamoxifen, or who have had radiation therapy, chemotherapy, or previous oophorectomy.⁴
• Reduced oestrogen levels can also cause atrophic vaginitis in women who are postpartum and/or breastfeeding.²

Many women will be found to have atrophic vaginitis as an incidental finding during the taking of a cervical smear, but others may present with symptoms such as:

• Dyspareunia
• White or yellow discharge
• Lack of vaginal secretions
• Burning or itching of the vagina or vulva
• Candidal infections
• Problems with sexual intercourse and associated distress
• Post coital spotting
• Urinary symptoms may occur: incontinence and/or recurrent urinary tract infections. Lack of oestrogen also causes atrophic urethritis, and the changes in vaginal pH and flora may be factors which predispose to recurrent urinary infections.⁵

• The differential diagnosis should include vaginal infections e.g. bacterial vaginosis, trichomonas. Atrophic vaginitis predisposes the vagina to bacterial infection.²
• Candidal infections may occur for other reasons e.g. diabetes.
• Local irritation from other sources e.g. soap, panty liners, spermicides, condoms etc.
• The use of biological washing powder and tight fitting clothes such as jeans may produce similar symptoms.
• Women with unexplained, persistent vaginal discharge need investigation to exclude gynaecological neoplasms.

History, with particular attention to menstrual history and aetiological factors as above.

Vaginal examination: the vagina will appear smooth and shiny; there may be some contact bleeding or small fissures. Narrowing of the introitus may be present making full examination difficult and uncomfortable.

Investigations

• In post-menopausal women, no other investigation is usually required, although dip-stick testing of urine may be performed as a routine measure to look for diabetes.
• Consider taking swabs to identify possible bacterial infections.
• Other possible investigations include²:
  • Vaginal pH testing (pH stick in vaginal vault - will be more alkaline in atrophic vaginitis
  • Vaginal cytology which can show lack of maturation of the vaginal epithelium typical of atrophic vaginitis
  • Ultrasound for endometrial thickness

Options are as follows:

1. Vaginal lubricants, particularly during sexual intercourse, are often helpful, though less effective than HRT.^7,8
2. Topical or Systemic Oestrogen HRT - As atrophic vaginitis occurs as a result of falling oestrogen levels, replacing oestrogen, either locally or systemically, will result in an improvement in the vaginal epithelium and a reduction in symptoms.^7,9,10
   • Topical HRT - (see specific record - Topical HRT). Topical oestrogen preparations have the advantage of using lower overall doses of oestrogen than systemic HRT - however, the long term safety of vaginal oestrogen treatment is not known. There may be significant systemic absorption of vaginal oestrogen preparations; hence the same concerns apply as for systemic oestrogen HRT, e.g. endometrial hyperplasia.^10,7
     
     Choice of vaginal oestrogen preparations: The evidence so far suggests that:
     • Vaginal tablets (pessaries) have low systemic absorption¹¹ and are least likely to cause endometrial hyperplasia.
     • Vaginal rings are more popular with women, but may give greater systemic oestrogen absorption.
     • Conjugated equine oestrogen creams seem more likely to cause endometrial hyperplasia and side effects.^10,7
     For topical HRT, most guidelines advise that the smallest dose possible to alleviate symptoms should be used for short periods of time only. The need for continued treatment should be regularly assessed with treatment free intervals.
     
     Some authors and studies suggest that long term vaginal oestrogens may be safe and do not require monitoring.^9,11,12
     
     
   • Systemic HRT (either oestrogens or tibolone) relieves vaginal symptoms, but carries significant risks in terms of venous thrombosis, breast cancer, stroke and possibly heart disease.^8,9

Drug treatment for urinary symptoms

A review of trials found that taking extra oestrogen (systemic or vaginal) may help both stress and urge incontinence, but oestrogen combined with progestogen treatment may make incontinence worse. The improvement with oestrogen was greatest for urge incontinence. There was no evidence about whether benefits continue after stopping treatment.⁵ Other sources suggest that oestrogen alone is not effective for stress incontinence, although oestrogen combined with alpha agonists may help.⁷

Topical oestrogen for 6-8 months may reduce recurrence of urinary tract infections in women who are susceptible to recurrent UTIs.⁸

The author is grateful to Dr Cathy Jackson for her previous work on this record.