Atrophic vaginitis

Synonyms: genitourinary syndrome of menopause, urogenital atrophy

What is atrophic vaginitis?

Atrophic vaginitis is very common in postmenopausal women, due to the falling levels of oestrogen. The term genitourinary syndrome of menopause (GSM) is now usually used instead of vulvovaginal atrophy or atrophic vaginitis.¹

It is defined as 'a group of chronic, progressive, hypo-oestrogenic conditions, including vulvovaginal atrophy, atrophic vaginitis, and bladder and urethral dysfunctions'.²

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.

• 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.

What causes atrophic vaginitis?³

Surveys have shown that around half of postmenopausal women have experienced vulvovaginal symptoms, most commonly vaginal dryness. However, many women do not seek professional help or advice regarding their symptoms.

The following can lead to atrophic vaginitis:

• 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.

Atrophic vaginitis signs and symptoms^{4 5}

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. Women are poorly aware that vulvovaginal atrophy is a chronic condition with a significant impact on sexual health and quality of life and that effective and safe treatments may be available.

Symptoms

• There may be no symptoms.

• Dryness of the vagina is the most common symptom, affecting up to 93% of women; this symptom is characterised as being moderate to severe in intensity in 68% of the cases.

• 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.

• Decreased arousal, desire and orgasm.

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.

  • Prolapse of urethra and/or vagina.

• Atrophic vaginitis may be diagnosed by the practice nurse when a smear is being taken.

Investigations⁴

• 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 postmenopausal 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 may be considered (uncontrolled diabetes can contribute to symptoms).

• Assessment tools may be useful in evaluating severity of symptoms and their response to treatment.⁶

Differential diagnosis

• 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.

• Hot flushes mimic thyroid disease, malignancies, hypoglycaemia, carcinoid, and phaeochromocytoma.

Atrophic vaginitis treatment ^{7 5}

In most cases, it can be managed successfully. 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.

A number of different treatments are available. These include vaginal lubricants and moisturisers, vaginal oestrogen and hormone replacement therapy (HRT).

The principles of management are:

• Restoration of urogenital physiology.

• Alleviation of symptoms.

Non-hormonal treatments

Personal lubricants and moisturisers can be effective at relieving discomfort and pain during sexual intercourse for women with mild to moderate vaginal dryness, particularly those who have a genuine contra-indication to oestrogen, or who choose not to use oestrogen. Regular sexual activity can be beneficial for many women.⁸

Lubricants

• These provide short-term relief.

• They can improve dryness during intercourse.

• There is no evidence that they have any long-term beneficial therapeutic effects.

• Some are water based non-hormonal vaginal lubricants.

• Others are silicone-based lubricants.

Moisturisers

• These are bio-adhesive so attach to mucin and epithelial cells on the vaginal wall and therefore retain water.

• They can also lower vaginal pH.

• Numerous preparations are available over the counter.

• They are non-hormonal vaginal moisturisers.

• Typical use might be one application (2.5 g) three times per week for an initial period of three months. It can be continued longer term if it is beneficial. It can be used more or less frequently, depending on the severity of the woman's dryness. It is safe to use daily.

• These should be used regularly rather than during sexual intercourse.

• NB: Vaseline® is not recommended. It can break down the latex in condoms or damage sex toys.

The efficacy of lubricants and moisturisers is generally 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.⁹

Laser treatment^{10 11}
In 2021 the National Institute for Health and Care Excellence (NICE) issued guidance for the use of transvaginal laser therapy for urogenital atrophy . As there is inadequate evidence on long-term safety and efficacy, it recommends that this procedure should only be used in the context of research. This was reiterated in the 2024 update of the menopause guideline.

Ospemifene¹²
Ospemifene is a selective oestrogen receptor modulator used to treat moderate-to-severe dyspareunia and moderate-to-severe vaginal dryness. Ospemifene (60-mg oral dose) reduces the severity of dyspareunia and has beneficial effects for vaginal dryness and bone as well as anti-oestrogenic effects on breast tissue. The most common side-effect is hot flushes. It is recommended second-line by NICE, or first-line for those who cannot use topical treatments due to difficulty in applying them, for example due to arthritis of the hands or other disability.

Hormonal treatments

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

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 as first-line treatment for those women with only vaginal symptoms and no menopausal symptoms.

• Around 10-25% of women receiving HRT still have symptoms and so will require topical oestrogen in addition to HRT.

Prasterone¹²
Prasterone is a synthetic DHEA equivalent that is approved for the treatment of moderate-to-severe dyspareunia. Prasterone is taken vaginally, once daily at bedtime, and has no restrictions on duration of use. It is associated with significant improvements in the severity of vaginal symptoms while serum levels of estradiol and testosterone remain within normal limits. It is recommended second-line by NICE.

Topical treatments ⁵¹³
See also the separate HRT - topical vaginal article.

• There are various preparations available, including rings, vaginal tablets and creams. These are all equally effective for treating vaginal atrophy.

• It is common to have more vaginal discharge with creams. This may be an advantageous side-effect in sexually active women.

• Individual preference is important when deciding on which type of topical treatment to prescribe.

• Topical HRT is sometimes used prior to prolapse repair surgery in postmenopausal women with evidence of epithelial atrophy.

• Vaginal oestrogens can be really effective in patients with urinary urgency, frequency or nocturia, urinary incontinence and recurrent UTIs.

• There is no evidence that topical oestrogen causes endometrial proliferation after long-term use.¹⁴

• Low-dose topical oestrogen does not therefore need to be given with systemic progestogens.

• Long-term low-dose topical oestrogen is safe.

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).

Management in women who have had breast cancer¹¹

This was added to the 2024 update of the NICE guideline on the menopause - their advice is as follows:

• Non-hormonal moisturisers and lubricants should be used first-line, but vaginal oestrogen can also be used.

• If the woman is using aromatase inhibitors, the GP and cancer specialist should work together to identify treatment options.

• If the breast cancer was oestrogen receptor negative, the use of vaginal oestrogen is unlikely to increase recurrence rate, as systemic absorption is minimal. It is likely to be safe.

• There is no data for women who had an oestrogen receptor positive breast cancer; we do not know if vaginal oestrogen could increase the risk of recurrence. Any such increase would be at least partly mitigated by the use of tamoxifen.

Prognosis¹⁵

Vasomotor symptoms improve over 2-5 years but (rarely), may last to up to 20 years post-menopause. The duration varies with ethnicity - Asian women usually having a shorter duration and longer in African American women.

Hormonal treatment can reduce the frequency and severity of hot flushes by 75% and 87% respectively. It also improves the osteoporosis risk and subsequent risk of fracture. The genitourinary symptoms (such as dryness and itch) do not improve over time and return once the treatment is stopped.