Condition: Atrophic Vaginitis // Vaginal Atrophy // Vulvovaginal Atrophy
Brief Overview: Vaginal atrophy, also known as atrophic vaginitis, refers to thinning, drying, and inflammation of the vaginal walls due to decreased estrogen levels. It most commonly occurs after menopause but can also occur postpartum, during lactation, or in individuals undergoing certain medical therapies (e.g., anti-estrogen treatments).
This condition can cause vaginal dryness, irritation, burning, pain with intercourse (dyspareunia), and urinary symptoms. It is chronic and progressive without treatment, but symptoms can be effectively managed with local or systemic therapies.
Prevalence: According to UpToDate, “The prevalence of GSM is not well established. Most menopausal patients or patients in a hypoestrogenic state will develop GSM.”
Etiology: According to UpToDate, “GSM results predominantly from a decline in serum estrogen levels. This is most commonly due to natural or surgical menopause but may also occur with premature ovarian insufficiency or, temporarily, during the postpartum period or lactation, or due to hypothalamic amenorrhea or antiestrogenic drugs.”
GSM = genitourinary syndrome of menopause (vulvovaginal atrophy)
Risk Factors:
- Natural or surgical menopause
- Postpartum or breastfeeding (low estrogen states)
- Use of anti-estrogen therapies (e.g., tamoxifen, aromatase inhibitors)
- Primary ovarian insufficiency
- Ovarian failure from radiation or chemotherapy
- Hypothalamic amenorrhea or amenorrhea in the setting of severe SLE or RA combined with glucocorticoid therapy
- Smoking (decreases estrogen levels and tissue oxygenation)
- Lack of sexual activity (decreased blood flow)
- Oophorectomy
Commonly Associated Conditions:
- Menopause/post-menopause
- Recurrent UTIs
- Vaginal stenosis
Common Medications:
- Vaginal estrogen therapy
- Hormonal medications (DHEA, oral ospemifene)
- Testosterone – off-label
Common Labs, Imaging, and Tests:
- Pelvic exam
Common Symptoms:
- Vaginal dryness, burning
- Dyspareunia
- Urinary frequency, urgency, dysuria, hematuria
- Vaginal discharge (leukorrhea)
- Recurrent bladder infections, UTIs
- Sexual dysfunction
- Postcoital bleeding
Common Treatments:
- Nonhormonal vaginal moisturizers and lubricants
- Pelvic floor physical therapy, vaginal dilators
Physical Findings:
- Pale, thin, dry vaginal mucosa
- Loss of vaginal rugae
- Fragile mucosa that may bleed with minimal trauma
- Introital retraction
- Vaginal discharge that is thin, white, and nonodorous
Potential Complications and Contraindications:
- Increased susceptibility to infection and irritation
- Dyspareunia leading to sexual dysfunction or relationship strain
- Vaginal stenosis with chronic untreated atrophy
- Discomfort and decreased quality of life
- Relative contraindications: estrogen therapy may be avoided or used cautiously in women with history of estrogen-sensitive malignancy (e.g., breast cancer)—consultation with oncology or gynecology is required.
General Health and Lifestyle Guidance:
- Encourage regular sexual activity (unless uncomfortable/painful) or vaginal dilator use to maintain elasticity and blood flow.
- Use of moisturizers and lubricants for comfort and symptom relief.
- Smoking cessation to improve tissue health and circulation.
- Maintain good vulvovaginal hygiene (gentle, fragrance-free products).
- Regular follow-up with gynecology or primary care for symptom monitoring and treatment adjustment.
- Educate on early reporting of postmenopausal bleeding, persistent pain, or lesions.
Suggested Questions to Ask Patients:
- When did your symptoms (dryness, pain, irritation) begin?
- Are symptoms affecting daily comfort or intimacy?
- Are urinary symptoms (frequency, urgency, infections) present?
- Are you using any vaginal moisturizers or hormone therapies currently?
- Do you have a history of breast cancer or hormone-sensitive conditions?
- Are you open to using topical estrogen or other treatments?
- How have these symptoms impacted your quality of life or relationships?
Suggested Talking Points:
- This is a very common condition that happens to many women after menopause.
- Topical estrogen is the most effective treatment and works locally, with minimal absorption.
- Non-hormonal options are also available for those who can’t or prefer not to use estrogen.
- You don’t need to live with discomfort—treatments are highly effective.
- Sexual activity (unless uncomfortable/painful) or gentle vaginal stretching can help maintain vaginal elasticity.
- Report any unexpected bleeding or persistent pain promptly.
- Always ask your healthcare provider for specific advice on when to call to report symptoms, and when to seek urgent/emergency care.
Sources:
- https://www.uptodate.com/contents/vaginal-dryness-the-basics?search=atrophic%20vaginitis&topicRef=5443&source=see_link
- https://www.uptodate.com/contents/genitourinary-syndrome-of-menopause-vulvovaginal-atrophy-treatment?search=atrophic%20vaginitis&source=search_result&selectedTitle=1~132&usage_type=default&display_rank=1#H15
- https://www.uptodate.com/contents/genitourinary-syndrome-of-menopause-vulvovaginal-atrophy-clinical-manifestations-and-diagnosis?search=atrophic%20vaginitis&topicRef=5443&source=see_link