Atrophic Vaginitis

Aka: Atrophic Vaginitis, Vaginal Atrophy, Vulvovaginal Atrophy, Genitourinary Syndrome of Menopause

II. Epidemiology

  1. Prevalence: 50% of post-menopausal women within first 3 years

III. Causes

  1. Menopause (most common)
  2. Antiestrogen medications (e.g. Raloxifene, Tamoxifen, GnRH agonists)
  3. Breast Feeding women
  4. Central Amenorrhea

IV. Pathophysiology

  1. Related to decreased Estrogen with Menopause
  2. Vaginal effects
    1. Vaginal epithelium thins with decreased lubrication
    2. Vaginal canal narrowing
      1. Bleeding or pain on intercourse
    3. Vulvar mucosa thinning
      1. Vulvar burning or irritation
      2. Dyspareunia due to introitus narrowing
    4. Glycogen loss with altered Vaginal pH and flora

V. Symptoms

  1. Vaginal Dryness
  2. Vaginal or vulvar burning, itching or irritation
  3. Dyspareunia
  4. Vaginal Discharge
  5. Urinary urgency

VI. Signs

  1. Vaginal Discharge that is thin or clear
  2. Vaginal introitus narrowing
  3. Loss of labia minora
  4. Vaginal mucosa changes
    1. Mucosa is thin, pale and dry with reduced elasticity
    2. Vaginal rugae lost
    3. Mucosa may be irritated and friable

VII. Labs

  1. Vaginal pH 5 to 7

VIII. Complications

  1. Recurrent Urinary Tract Infections

IX. Management

  1. See Menopause
  2. Symptomatic measures (first-line for mild symptoms)
    1. Vaginal Moisturizers (Replens) applied three times weekly
    2. Vaginal Lubricant (e.g. Astroglide) applied before intercourse
  3. Topical Vaginal Estrogen (second-line for moderate symptoms)
    1. Does not require systemic Progesterone (in intact Uterus) if used <1 year
    2. Low dose Topical Estrogen (e.g. Vagifem, Estring, Estrace or Premarin vaginal cream)
    3. Reduces risk of Recurrent Urinary Tract Infection
    4. Suckling (2006) Cochrane Database Syst Rev (4): CD001500 [PubMed]
  4. Intravaginal Prasterone (Intrarosa, synthetic DHEA)
    1. Indicated in Dyspareunia and moderate to severe Vulvovaginal Atrophy
    2. Although marketed as non-Estrogen, it is DHEA which converts to Estrogens and androgens in vaginal tissue
  5. Systemic Estrogens (third-line for refractory symptoms)
    1. Precautions
      1. Do not use Unopposed Estrogen with intact Uterus (requires concurrent Progesterone)
    2. Continuous Estrogen Replacement
    3. Sequential Estrogen Replacement
    4. Transdermal Estrogen Replacement
    5. Higher dose Topical Estrogen (e.g. FemRing)
      1. Requires Progesterone (in intact Uterus), unlike low dose Topical Estrogens
  6. Other options (refractory symptoms and unable to use Estrogens)
    1. Osphena (ospemifene)
      1. Selective Estrogen receptor modifier (SERM) with Vaginal Estrogenic effect (unlike Raloxifene and Tamoxifen)
      2. FDA-approved for severe Dyspareunia
      3. Risk of venous thrombosis and Hot Flashes (similar to Raloxifene and Tamoxifen)
      4. Expensive ($160) with limited indications beyond other measures
      5. Dose: 60 mg once daily with food
      6. (2013) Prescr Lett 20(6):33
    2. Fractional Carbon-Dioxide Laser Therapy
      1. Results in microabrasions that promote increased Blood Flow and thicken vaginal tissue

X. References

  1. Hill (2016) Am Fam Physician 94(11): 884-9 [PubMed]
  2. Ringel (2020) Am Fam Physician 102(9):550-7 [PubMed]
  3. Seehusen (2014) Am Fam Physician 90(7): 465-70 [PubMed]

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Related Studies

Ontology: Postmenopausal atrophic vaginitis (C0156409)

Concepts Disease or Syndrome (T047)
ICD9 627.3
ICD10 N95.2
SnomedCT 156054004, 52441000
English Postmenopausal atrophic vaginitis, Postmenop atrophic vaginitis, postmenopausal atrophic vaginitis, postmenopausal atrophic vaginitis (diagnosis), Atrophic vaginitis, Senile (atrophic) vaginitis, Vaginitis;senile, atrophic vaginitis, Postmenopausal atrophic vaginitis (disorder), Senile atrophic vaginitis, Senile vaginitis, atrophic; vaginitis, postmenopausal, postmenopausal; atrophic vaginitis, postmenopausal; vaginitis, atrophic, senile; vaginitis, vaginitis; postmenopausal atrophic, vaginitis; senile, senile vaginitis
Dutch postmenopauzale atrofische vaginitis, seniele vaginitis, atrofisch; vaginitis, postmenopauzaal, postmenopauzaal; atrofische vaginitis, postmenopauzaal; vaginitis, atrofisch, seniel; vaginitis, vaginitis; postmenopauzaal atrofisch, vaginitis; seniel, Postmenopauzale atrofische vaginitis
French Vaginite sénile, Vaginite atrophique postménopausique
German senile Vaginitis, postmenopausale atrophische Vaginitis, Atrophische Kolpitis in der Postmenopause
Italian Vaginite senile, Vaginite atrofica postmenopausale
Portuguese Vaginite atrófica pós-menopáusica, Vaginite senil
Spanish Vaginitis atrófica postmenopáusica, Vaginitis senil, vaginitis atrófica posmenopáusica, vaginitis atrófica postmenopáusica, vaginitis atrófica senil (trastorno), vaginitis atrófica senil, vaginitis senil
Japanese 老人性腟炎, 閉経後萎縮性腟炎, ﾛｳｼﾞﾝｾｲﾁﾂｴﾝ, ﾍｲｹｲｺﾞｲｼｭｸｾｲﾁﾂｴﾝ
Czech Postmenopauzální atrofická kolpitis, Stařecká kolpitis
Korean 폐경기후 위축성 질염
Hungarian postmenopausalis atrophiás vaginitis, senilis vaginitis
Derived from the NIH UMLS (Unified Medical Language System)

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