Vagina
Atrophic Vaginitis
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Atrophic Vaginitis
, Vaginal Atrophy, Vulvovaginal Atrophy, Genitourinary Syndrome of Menopause
See Also
Menopause
Dyspareunia
Vaginitis
Epidemiology
Prevalence
: 50% of post-menopausal women within first 3 years
Causes
Menopause
(most common)
Vulvovaginal Atrophy and dryness symptomatic in 50% of postmenopausal women (due to low
Estrogen
)
Only 25% of symptomatic women seek medical care
Antiestrogen medications (e.g.
Raloxifene
,
Tamoxifen
,
GnRH agonist
s)
Breast Feeding
women
Central
Amenorrhea
Pathophysiology
Related to decreased
Estrogen
with
Menopause
Vaginal effects
Vaginal epithelium thins with decreased lubrication
Vaginal canal narrowing
Bleeding or pain on intercourse
Vulva
r mucosa thinning
Vulva
r burning or irritation
Dyspareunia
due to introitus narrowing
Glycogen loss with altered
Vaginal pH
and flora
Symptoms
Vaginal Dryness
Vaginal or vulvar burning, itching or irritation
Dyspareunia
Vaginal Discharge
Urinary urgency
Signs
Vaginal Discharge
that is thin or clear
Vaginal introitus narrowing
Loss of labia minora
Vaginal mucosa changes
Mucosa is thin, pale and dry with reduced elasticity
Vaginal rugae lost
Mucosa may be irritated and friable
Labs
Vaginal pH
5 to 7
Complications
Recurrent Urinary Tract Infection
s
Management
See
Menopause
Symptomatic measures (first-line for mild symptoms)
Vaginal
Moisturizer
s (Replens) applied three times weekly
Vaginal Lubricant
(e.g. Astroglide) applied before intercourse
Topical
Vaginal Estrogen
(second-line for moderate symptoms)
Does not require systemic
Progesterone
(in intact
Uterus
) if used <1 year
Low dose
Topical Estrogen
(e.g.
Vagifem
,
Estring
, Estrace or Premarin vaginal cream)
Reduces risk of
Recurrent Urinary Tract Infection
Suckling (2006) Cochrane Database Syst Rev (4): CD001500 [PubMed]
Intravaginal
Prasterone
(
Intrarosa
, synthetic
DHEA
)
Vaginal Dehydroepiadrosterone that increases epithelial thickness and decreases
Dyspareunia
Indicated in
Dyspareunia
and moderate to severe Vulvovaginal Atrophy
Although marketed as non-
Estrogen
, it is
DHEA
which converts to
Estrogen
s and androgens in vaginal tissue
Expensive (>$200/month)
Systemic
Estrogen
s (third-line for refractory symptoms)
Precautions
Do not use
Unopposed Estrogen
with intact
Uterus
(requires concurrent
Progesterone
)
Continuous Estrogen Replacement
Sequential Estrogen Replacement
Transdermal
Estrogen Replacement
Higher dose
Topical Estrogen
(e.g.
FemRing
)
Requires
Progesterone
(in intact
Uterus
), unlike low dose
Topical Estrogen
s
Other options (refractory symptoms and unable to use
Estrogen
s)
Osphena (ospemifene)
Selective
Estrogen
receptor modifier (
SERM
) with
Vaginal Estrogen
ic effect (unlike
Raloxifene
and
Tamoxifen
)
FDA-approved for severe
Dyspareunia
Risk of venous thrombosis and
Hot Flashes
(similar to
Raloxifene
and
Tamoxifen
)
Expensive (> $200/month) with limited indications beyond other measures
Dose: 60 mg once daily with food
(2013) Prescr Lett 20(6):33
Fractional Carbon-Dioxide Laser Therapy
Results in microabrasions that promote increased
Blood Flow
and thicken vaginal tissue
Decreases
Dyspareunia
Similar efficacy to
Vaginal Estrogen
s, but not FDA approved and risk of burns and scarring
https://www.fda.gov/medical-devices/safety-communications/fda-warns-against-use-energy-based-devices-perform-vaginal-rejuvenation-or-vaginal-cosmetic
Paralso (2020) Menopause 27(1):50-6 [PubMed]
References
Hill (2016) Am Fam Physician 94(11): 884-9 [PubMed]
Hill (2021) Am Fam Physician 103(10):597-604 [PubMed]
Ringel (2020) Am Fam Physician 102(9):550-7 [PubMed]
Seehusen (2014) Am Fam Physician 90(7): 465-70 [PubMed]
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