Basics
Description
- Thinning of the vaginal epithelium with associated inflammatory changes in response to decreased endogenous estrogen
- Can also affect urinary epithelium
- Usually requires prolonged estrogen deficiency
- Most women with mild-to-moderate vaginal atrophy are asymptomatic.
Epidemiology
Incidence
True incidence and prevalence are unknown, because many women are asymptomatic and up to 25% of symptomatic women do not seek treatment.
Prevalence
Symptomatic in up to 50% of postmenopausal women
Risk Factors
- Any low estrogen state
- Cigarette smoking
- Decreased frequency of sexual intercourse
General Prevention
Regular sexual intercourse
Pathophysiology
Lack of estrogen alters the normal urogenital environment.
- Atrophy of vaginal epithelium
- Increased subepithelial connective tissue
- Decreased glycogen levels
- Loss of normal population of lactobacilli
- Decreased lactic acid production
- Increased vaginal pH
- Overgrowth of gram-negative rods
- Decreased blood flow
- Decline in normal vaginal secretions
Etiology
Any condition causing significant decrease in circulating estrogen levels:
- Menopause
- Oophorectomy
- Postpartum
- Anti-estrogenic medications
- Danazol
- Gonadotropin-releasing hormone (GnRH) agonists (such as goserelin, leuprolide, nafarelin)
- Progestins (such as medroxyprogesterone acetate)
- Tamoxifen (premenopausal use)
- Hyperprolactinemia
- Prolonged breastfeeding
- Medications
- Hypothalamic-pituitary dysfunction
- Ovarian failure
- Radiation therapy
- Chemotherapy
- Immune disorders
Associated Conditions
- Urinary incontinence
- Urinary tract infection
- Pelvic organ prolapse
Diagnosis
History
- Use of sanitary pads, soaps, lubricants, feminine hygiene products, spermicides, or other potential irritants
- Medication use
- Recent or recurrent urinary tract infection
- Sexual history, including risks for sexually transmitted infections
- Menstrual history, including date of last menstrual period
- Reproductive history, including recent or current breastfeeding
- Symptoms
- Vaginal
- Dryness, itching
- Occasional spotting
- Pain during intercourse
- Burning sensation or spotting after intercourse
- Leukorrhea
- Yellow, malodorous discharge
- Urinary
- Frequency, urgency
- Painful urination
- Hematuria
Physical Exam
To avoid vaginal trauma, evaluate width and depth of introitus before attempting to insert a speculum.
- External genitalia
- Thinning of pubic hair
- Decreased turgor and elasticity
- Vulvar atrophy
- Vulvar lesions
- Fusion of labia minora
- Vagina
- Narrowed introitus
- Pale, smooth, shiny mucosa, may be friable
- Loss of folds
- Dryness
- Fissures
- Diffuse or patchy erythema
- Petechiae or visible vessels
- Watery or serosanguineous discharge
- Cystocele, rectocele, uterine prolapse
- Urinary
- Urethral polyp or caruncle
- Eversion of urethral mucosa
Tests
Primarily a clinical diagnosis, but testing may be helpful if diagnosis unclear.
Lab
- Urinalysis and urine culture and sensitivity to evaluate for urinary tract infection
- Serum estrogen level, although many assays lack sensitivity
Imaging
Transvaginal ultrasonography: Thinning of endometrial stripe (<4-5 mm) supports estrogen deficiency.
Surgery
- Vaginal pH taken from upper third of side wall: Elevated (5.0-7.0)
- Microscopy of saline and potassium hydroxide wet mounts taken from upper third of vaginal side wall
- Increased numbers of polymorphonuclear leukocytes
- Decreased numbers of lactobacilli
- May show evidence of coexisting infection
- Papanicolaou smear to assess for estrogen effect: Take specimen from upper third of vaginal side wall and request maturation index to distinguish from smear taken for cervical cytology
- Increased number of immature squamous epithelial cells
- Inflammatory exudates
- Cervical cultures for sexually transmitted infections if indicated
Cervical cytology may be falsely positive (atypical squamous cells or low-grade squamous intraepithelial lesion) in low estrogen state. Consider treating with topical estrogen and repeating test.
Differential Diagnosis
- Bacterial vaginosis
- Trichomoniasis
- Vaginal candidiasis
- Vulvar dermatitis
- Contact irritation
- Lichen planus
Treatment
Medication
- Need for treatment in asymptomatic women is unknown.
- Nonhormonal vaginal moisturizers and lubricants should be considered first-line treatment for mild symptoms (1)[C].
- Regular use of vaginal moisturizers can help relieve vaginal itching and irritation, while personal lubricants can reduce intercourse-related pain.
- Polycarbophil-based vaginal moisturizers may promote a more acidic pH.
Oil-based products can cause deterioration of latex condoms.
- Estrogen restores vaginal epithelium, pH, and moisture and is indicated for moderate-to-severe symptoms (1)[C].
- Topical estrogen therapy is preferred for isolated atrophic vaginitis given concerns about long-term risks of malignancy and cardiovascular disease with systemic therapy.
- Few well-designed trials of local therapy
- All forms appear effective for vaginal symptoms (2)[B].
- The safety of local therapy beyond 1 year is unknown.
- Use the lowest effective dose for the shortest duration possible (1)[C].
- Very low dose systemic estrogen therapy for vasomotor symptoms may not adequately treat urogenital symptoms. Addition of local estrogen may limit total estrogen dose compared with use of higher dose systemic therapy.
- Although estrogen exposure is assumed to be minimized with local therapy, systemic absorption occurs. Creams have highest association with systemic absorption, followed by tablets then rings.
- Consider addition of cyclic or daily progestin to prevent endometrial hyperplasia in women with an intact uterus, especially with long-term or higher dose treatment (>0.5 mg estradiol daily) (2)[B].
- The cream may be less acceptable to women than vaginal tablet or ring, which may affect adherence.
- May be difficult to accurately measure out lower doses of estrogen creams.
- Estrogen contraindicated in known or suspected breast or estrogen-dependent cancers, undiagnosed vaginal bleeding, history of thromboembolism, active thrombophlebitis, or pregnancy.
- Use in a woman with breast cancer with severe urogenital atrophy unresponsive to nonhormonal treatments should be considered only after careful discussion of risks with the patient and her oncologist (1)[C].
- Topical estrogen use may interfere with effectiveness of aromatase inhibitor therapy in breast cancer (3)[B].
- Estrogen use controversial in breastfeeding
- Secreted in breast milk, decreased quantity and quality
- Systemic estrogen replacement may induce ovulation.
- The benefits of local estrogen therapy or combination oral contraceptives in women more than 6 months postpartum may outweigh the risks.
- Conjugated estrogens vaginal cream (0.625 mg/g)
- 0.5-2 g vaginally daily for 3 weeks, then tapered to lowest effective dose twice weekly; administer cyclically (3 weeks on, 1 week off)
- Estradiol 0.01% vaginal cream
- 2-4 g vaginally daily for 1-2 weeks, then tapered to lowest effective dose over 1-2 weeks; administer 1-3 times weekly for maintenance
- Estradiol 0.01 mg vaginal tablet
- 1 tablet vaginally daily for 2 weeks, then twice weekly for maintenance
- Estradiol vaginal ring (0.0075 mg/day)
- Silicone ring placed vaginally every 3 months
- May not be appropriate for women with narrow, short, or stenosed vagina.
- Expulsion may be more common in women with prior hysterectomy.
- Systemic estrogen therapy may be indicated in postmenopausal women with atrophic vaginitis in addition to moderate-to-severe vasomotor symptoms or in women taking long-term GnRH agonists.
- Women with an intact uterus require cyclic or continuous progestin to prevent endometrial hyperplasia and endometrial cancer.
Additional Treatment
General Measures
- Avoid tight-fitting clothing and synthetic undergarments.
- Avoid potential irritants such as soaps, sanitary pads, and feminine hygiene products.
- Discontinue offending medication if possible.
- Treat any coexisting infectious cause of vulvovaginitis.
- Weigh the potential severity of the symptoms against benefits of prolonged breastfeeding.
Complementary and Alternative Medicine
Many agents, including phytoestrogens, black cohosh, dong quai, ginseng, and red clover, have been used to treat menopausal symptoms, but information on their effectiveness is limited.
Ongoing Care
Follow-Up Recommendations
Patient Monitoring
- Review use of estrogen every 3-6 months and attempt to taper or discontinue its use.
- An annual clinical breast exam and mammography is recommended for women on estrogen therapy.
- Endometrial biopsy to evaluate postmenopausal bleeding, especially in women on estrogen therapy.
- Need for transvaginal ultrasound to evaluate endometrium in asymptomatic women on prolonged estrogen therapy is unknown.
Prognosis
- Many women are asymptomatic.
- Symptoms usually improve markedly within 2 weeks of local estrogen therapy, but may recur after treatment is stopped.
Complications
- Uterine bleeding secondary to endometrial proliferation, breast pain, perineal pain induced by estrogen use
- Vaginal irritation secondary to local estrogen therapy
References
1 The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Menopause. 2007;14:355-369. [View Abstract]2Suckling JA, Kennedy R, Lethaby A. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2009, Issue 1. Art. No. CD001500. DOI: 10.1002/14651858.CD001500.pub2.3Kendall A, Dowsett M, Folkerd E. Caution: Vaginal estradiol appears to be contraindicated in postmenopausal women on adjuvant aromatase inhibitors. Ann Oncol. 2006;17:584-587. [View Abstract]
Additional Reading
1Al-Baghdadi O, Ewies AA Topical estrogen therapy in the management of postmenopausal atrophy: An up-to-date overview. Climacteric. 2009;12:91-105. [View Abstract]2MacBride MB, Rhodes DJ, Shuster LT Vulvovaginal atrophy. Mayo Clin Proc. 2010;85:87-94.
Codes
ICD9
627.3 Postmenopausal atrophic vaginitis
ICD10
N95.2 Postmenopausal atrophic vaginitis
SNOMED
- 52441000 atrophic vaginitis (disorder)
- 408386002 perimenopausal atrophic vaginitis (disorder)
Clinical Pearls
- Common diagnosis in postmenopausal women, but can occur with any prolonged low estrogen state.
- Many women are asymptomatic.
- Estrogen therapy is effective, but the risks and benefits for the individual woman should be weighed carefully.
- Patient preference should guide selection of treatment.