Atrophic Vaginitis

Question 1

What is atrophic vaginitis?

Answer 1

Atrophic vaginitis refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen. Atrophic vaginitis can also be referred to as genitourinary syndrome of menopause. It occurs in women entering the menopause.

Question 2

How does epithelial lining of vagina and urinary tract respond to oestrogen?
Menopause?

Answer 2

The epithelial lining of the vagina and urinary tract responds to oestrogen by becoming thicker, more elastic and producing secretions. As women enter the menopause, oestrogen levels fall, resulting in the mucosa becoming thinner, less elastic and more dry. The tissue is more prone to inflammation. There are also changes in the vaginal pH and microbial flora that can contribute to localised infections.

Question 3

How does oestrogen affect the pelvic organs?

Answer 3

Oestrogen also helps maintain healthy connective tissue around the pelvic organs, and a lack of oestrogen can contribute to pelvic organ prolapse and stress incontinence.

Question 4

How does atrophic vaginitis present?

Answer 4

Atrophic vaginitis presents in postmenopausal women with symptoms of:

Itching
Dryness
Dyspareunia (discomfort or pain during sex)
Bleeding due to localised inflammation
You should also consider atrophic vaginitis in older women presenting with recurrent urinary tract infections, stress incontinence or pelvic organ prolapse.

Question 5

Examination for atrophic vaginitis?

Answer 5

Examination of the labia and vagina will demonstrate:

Pale mucosa
Thin skin
Reduced skin folds
Erythema and inflammation
Dryness
Sparse pubic hair

Question 6

Management of atrophic vaginitis?

Note…

Answer 6

Vaginal lubricants can help symptoms of dryness. Examples include Sylk, Replens and YES.

Topical oestrogen can make a big difference in symptoms. Options include:

Estriol cream, applied using an applicator (syringe) at bedtime
Estriol pessaries, inserted at bedtime
Estradiol tablets (Vagifem), once daily
Estradiol ring (Estring), replaced every three months

Topical oestrogen shares many contraindications with systemic HRT, such as breast cancer, angina and venous thromboembolism. It is unclear whether long term use of topical oestrogen increases the risk of endometrial hyperplasia and endometrial cancer. Women should be monitored at least annually, with a view of stopping treatment whenever possible.