Introduction

Atrophic vaginitis is a common condition caused by falling levels of circulating oestrogen, frequently seen in post-menopausal women. It causes thinning and drying of the vaginal mucosa, which leads to both urinary and sexual problems. It can have a significant impact on quality of life and will often respond well to simple therapies. Therefore, it is an important topic to discuss with women who have been through the menopause.

Epidemiology

  • Incidence: 1000.00 cases per 100,000 person-years
  • Peak incidence: 50-60 years
Condition Relative
incidence
Bacterial vaginosis5.00
Vaginal candidiasis4.00
Atrophic vaginitis1
Lichen sclerosus0.10
Endometrial cancer0.03
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+

Pathophysiology

Atrophic vaginitis is caused by a reduction in levels of oestrogen in the body. It often occurs in post-menopausal women but can also be caused by other conditions, including;
  • Premature ovarian failure
  • Ovarian failure following chemotherapy and radiotherapy
  • Anti-oestrogenic medications such as tamoxifen and danazol
  • Postpartum changes in hormones

The changes seen in atrophic vaginitis are mainly related to changes in the vaginal tissues and local pH. The vaginal mucosa becomes drier, thinner and more easily broken, which can lead to epithelial irritation and inflammation.

The levels of glycogen production in the vagina fall, leading to a decrease in the numbers of lactobacilli which normally maintain the acidic environment of the vagina. Their absence allows an increasingly alkaline environment in which infection is more likely to develop.

Clinical features

Symptoms associated with atrophic vaginitis can be difficult for patients to discuss, so it is important to approach this topic in a sensitive manner.

Symptoms
  • Dryness of the vagina (57% of patients)
  • Local irritation (43% of patients)
    • This can present as pruritus, pressure and burning pain of the vagina.
  • Painful intercourse (22% of patients)
  • Vaginal bleeding, particularly post-coital bleeding or haematuria
  • Urinary symptoms
    • This can include increased frequency, recurrent urinary infections, painful urination, incontinence (both stress and urge) and pain on wiping after passing urine
  • Vaginal discharge
    • Usually white or yellow and occasionally malodorous

Signs
  • External examination
    • Reduced pubic hair
    • Loss of labial fat pad
    • Narrowing of vaginal introitus
    • Thinning of labia minora
  • Internal examination
    • Smooth, shiny vaginal mucosa with loss of skin folds
    • Dryness of mucosa
    • Loss of vaginal muscle tone
    • Erythema or bleeding

Differential diagnosis

Diagnosis of atrophic vaginitis will usually be clinical. Other conditions to exclude include:
  • Other causes of vaginal bleeding and post-menopausal bleeding should be considered, particularly sinister diagnoses such as endometrial cancer
  • Genitourinary infections, such as candidiasis, bacterial vaginosis or trichomonas
    • These may be the primary diagnosis, or can co-exist with atrophic vaginitis
  • Other skin conditions such as lichen sclerosus or lichen planus
  • Local reaction to irritants such as soaps, clothing or washing powder

Management

Effective management will usually focus on oestrogen replacement. NICE guidance, updated in 2019, recommends that topical oestrogen should be the first line in management of isolated atrophic vaginitis.

  • Topical oestrogens
    • Treatment of choice in management of atrophic vaginitis in absence of any other post-menopausal symptoms
    • Available as creams, rings, pessaries.
    • Treatments will take around 3 weeks to have any effect, with maximal effect noticeable within 3 months of starting
    • Long-term topical oestrogens are considered safe, with no effect on endometrial proliferation

  • Systemic HRT
    • Can be used in patients with other post-menopausal symptoms
    • As with any HRT, side effects and risks need to be discussed with patients
    • Up to 25% of patients taking systemic HRT will also experience vaginal dryness, so may require topical oestrogens in addition.

Patients taking any hormonal replacement should be instructed to contact their GP if they experience vaginal bleeding.

Other options for management include topical lubricants and moisturisers.