Vaginal atrophy, known also as atrophic vaginitis, vulvovaginal atrophy, or genitourinary syndrome, causes patients to show up to the doctor’s office with complaints of vaginal dryness and discomfort caused by decreased estrogen levels and consequent deterioration of the vaginal tissues.
Vaginal dryness is often the initial symptom, which women typically notice first during intercourse and then permanently. Pain and discomfort may occur during intercourse or urination. “Dyspareunia” is a medical word for pain during intercourse. Sometimes, vaginal spotting or watery discharge may be observed. Affected women experience also more frequent urinary tract infections and urinary incontinence.
This condition affects about half of women during or after the menopause. Generally, the symptoms do not subside without treatment. However, only approximately 25% of women with vaginal atrophy receive adequate therapy, probably due to the lack of sufficient awareness about this condition and the possible hesitancy of women to discuss their complaints with healthcare providers.
Vaginal atrophy is caused by decreased estrogen levels in the body. Estrogen levels decrease during the menopause - the average age of menopause onset is 51 years, although it varies markedly among women. Other reasons for reduced estrogen concentration include chemotherapy, radiation therapy, use of anti-estrogen drugs, and ovariectomy (ovary removal). Lower estrogen levels lead to decreased blood flow to the vaginal region, which in turn is associated with thinning of the vaginal walls and shortening of the vaginal canal. With the changes in vaginal epithelium, the vaginal pH increases, which predisposes the area to bacterial overgrowth and infections.
Doctors diagnose vaginal atrophy by obtaining a medical history and conducting a clinical examination. Laboratory tests (vaginal pH and vaginal maturation index) may be used to substantiate the diagnosis. Material for the laboratory tests can be obtained during the pelvic clinical examination. Vaginal pH is higher in patients with atrophic vaginitis than in healthy women, and the number of superficial cells is lower. Women who suspect they have vaginal atrophy should consult a healthcare provider to rule out other medical conditions that may initially present with similar symptoms especially infections or even cancerous lesions.
Vaginal atrophy can be treated with nonhormonal or hormonal treatments. When symptoms first show up, over-the-counter nonhormonal treatments, including vaginal lubricants and moisturizers, tend to be the first treatment. Vaginal moisturizers are water-based and are available as gels, liquids, or ovules. They help alleviate vaginal dryness, can be used safely for long periods of time, and should be applied regularly to achieve an optimal effect. Vaginal lubricants are water- or silicone-based and should be used at the time of intercourse. Some women may be hypersensitive to certain components of moisturizers or lubricants. Interestingly, studies have shown that locally applied Vitamin E may alleviate symptoms of vaginal atrophy. Pelvic floor physical therapy may also be beneficial in patients with dyspareunia.
For symptoms that are not sufficiently alleviated by vaginal moisturizers or lubricants, vaginally applied low-dose estrogen formulations are the treatment of choice. Vaginal estrogens are available in the form of vaginal tablets, creams, suppositories, or low-dose rings. The question whether locally applied estrogen preparations are absorbed systemically has been raised frequently. Different studies have shown that locally applied estrogens can be systemically absorbed but to a limited extent. Side effects that may occur with the application of local estrogen formulations include nausea, breast discomfort, vaginal bleeding, endometrial proliferation, and perineal pain.
Oral hormone therapy is reserved only for women who experience also vasomotor menopausal symptoms in addition to vaginal atrophy, and even this is less common than it used to be as oral hormone therapy has gone “out of style”. In case the vasomotor symptoms subside, the oral hormone therapy should be discontinued, and local treatment should be initiated. For women with intact uteruses, this therapy usually includes a combination of estrogen and progesterone. All labels of estrogen-containing drugs include a warning that they may slightly increase the risk of heart attack, stroke, breast cancer, and blood clots.
Special attention is required when treating vaginal atrophy in women with a history of or with active breast cancer. In these patients, nonhormonal treatments are favored, while systemic estrogen therapy is contraindicated. The duration of treatment for vaginal atrophy is determined on an individual basis and should continue for as long as distressing symptoms are present. Follow-up examinations with symptom evaluation, clinical exam, and laboratory assessment (vaginal pH and vaginal morphology) should be scheduled.
1. Kagan R, Kellogg-Spadt S, Parish SJ. Practical treatment considerations in the management of genitourinary syndrome of menopause. Drugs Aging. 2019 Oct;36(10):897-908.
2. Krychman ML. Vaginal atrophy: the 21st century health issue affecting quality of life. Medscape. 2020, March 21. https://www.medscape.org/viewarticle/561934.
3. Mac Bride MB, Rhodes DJ, Shuster LT. Vulvovaginal atrophy. Mayo Clin Proc. 2010;85(1):87-94.
4. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause 2013; 20:888.
5. Naumova I, Castelo-Branco C. Current treatment options for postmenopausal vaginal atrophy. Int J Womens Health. 2018;10:387-395.
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