Atrophic Vaginitis

Question 1

What is atrophic vaginitis?

Answer 1

Atrophic vaginitis refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen. Atrophic vaginitis can also be referred to as genitourinary syndrome of menopause. It occurs in women entering the menopause.

Question 2

Briefly describe the pathophysiology of atrophic vaginitis

Answer 2

The epithelial lining of the vagina and urinary tract responds to oestrogen by becoming thicker, more elastic and producing secretions. As women enter the menopause, oestrogen levels fall, resulting in the mucosa becoming thinner, less elastic and more dry. The tissue is more prone to inflammation. There are also changes in the vaginal pH and microbial flora that can contribute to localised infections.

Question 3

What is the role of oestrogen on connective tissue?

Answer 3

Oestrogen also helps maintain healthy connective tissue around the pelvic organs, and a lack of oestrogen can contribute to pelvic organ prolapse and stress incontinence.

Question 4

How does atrophic vaginitis present?

Answer 4

Atrophic vaginitis presents in postmenopausal women with symptoms of:

• Itching
• Dryness
• Dyspareunia (discomfort or pain during sex)
• Bleeding due to localised inflammation

You should also consider atrophic vaginitis in older women presenting with recurrent urinary tract infections, stress incontinence or pelvic organ prolapse. Treatment with topical oestrogen where appropriate may improve the symptoms of these conditions.

It is worth asking about symptoms of vaginal dryness and discomfort, as women will often be reluctant to bring it up during a consultation. It is straightforward to treat and can make a big difference to their quality of life.

Question 5

How does atrophic vaginitis present on examination?

Answer 5

Examination of the labia and vagina will demonstrate:

• Pale mucosa
• Thin skin
• Reduced skin folds
• Erythema and inflammation
• Dryness
• Sparse pubic hair

Question 6

Briefly describe the management of atrophic vaginitis

Answer 6

Vaginal lubricants can help symptoms of dryness. Examples include Sylk, Replens and YES.

Topical oestrogen can make a big difference in symptoms. Options include:

• Estriol cream, applied using an applicator (syringe) at bedtime
• Estriol pessaries, inserted at bedtime
• Estradiol tablets (Vagifem), once daily
• Estradiol ring (Estring), replaced every three months

Question 7

Wha are the contraindications of atrophic vaginitis?

Answer 7

Topical oestrogen shares many contraindications with systemic HRT, such as breast cancer, angina and venous thromboembolism. It is unclear whether long term use of topical oestrogen increases the risk of endometrial hyperplasia and endometrial cancer. Women should be monitored at least annually, with a view of stopping treatment whenever possible.