Atrophic Vaginitis

1. See Also
   1. Menopause
   2. Dyspareunia
   3. Vaginitis
2. Epidemiology
   1. Prevalence: 50% of post-menopausal women
3. 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
4. Symptoms
   1. Vaginal irritation
   2. Dyspareunia
   3. Vulvar burning or irritation
5. Signs
   1. Urinary urgency
   2. Vaginal Discharge that is thin or clear
   3. Vaginal mucosa changes
      1. Mucosa is thin, pale and dry with reduced elasticity
      2. Vaginal rugae lost
      3. Mucosa may be irritated and friable
6. Labs
   1. Vaginal pH 5 to 7
7. Complications
   1. Recurrent Urinary Tract Infections
8. 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. Suckling (2006) Cochrane Database Syst Rev (4): CD001500 [PubMed]
   4. 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
   5. 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. Risk of venous thrombosis and Hot Flashes (similar to Raloxifene and Tamoxifen)
         3. Expensive ($160) with limited indications beyond other measures
         4. Dose: 60 mg once daily with food
         5. (2013) Prescr Lett 20(6):33
9. References
   1. Hill (2016) Am Fam Physician 94(11): 884-9 [PubMed]
   2. Seehusen (2014) Am Fam Physician 90(7): 465-70 [PubMed]