Atrophic Vaginitis

Question 1

What is atrophic vaginitis?

Answer 1

• dryness + atrophy of the vaginal mucosa
• due to a lack of oestrogen
• affecting women entering the menopause

Question 2

What is the normal response of the vaginal tissue to oestrogen and how does this change in AV?

Answer 2

normal response:

• oestrogen causes the epithelial lining to become thicker, more elastic + produce secretions

during / after the menopause:

• the mucosa becomes thinner, less elastic + dry
• this tissue is more prone to inflammation

changes in vaginal pH and microbial flora can contribute to localised infections

Question 3

What are the other consequences of a lack of oestrogen?

Answer 3

• stress incontinence
• pelvic organ prolapse
• this is because oestrogen helps to maintain healthy connective tissue around pelvic organs

Question 4

What are the symptoms of atrophic vaginitis?

Answer 4

• itching
• dryness
• dyspareunia / discomfort during sex
• bleeding due to localised inflammation

always ask about vaginal dryness / discomfort as women often do not want to bring this up

Question 5

What other presentations should make you consider atrophic vaginitis?

Answer 5

postmenopausal women presenting with:

• pelvic organ prolapse
• stress incontinence
• recurrent UTIs

Question 6

What will examination of the vagina / labia reveal?

Answer 6

• pale mucosa
• thin skin
• sparse pubic hair
• reduced skin folds
• erythema / inflammation
• dryness

Question 7

What are the 2 options for treatment of vaginal atrophy?

Answer 7

• vaginal lubricants to help symptoms of dryness
• topical oestrogen to improve symptoms

Question 8

What are the options for topical oestrogen treatment?

Answer 8

Estriol cream:

• applied using an applicator (syringe) before bed

Estriol pessaries:

• inserted at bed time

Estradiol tablets:

• once daily

Estradiol ring:

• replaced every 3 months

Question 9

What are the contraindications to topical oestrogen?

Answer 9

they are the same as systemic HRT:

• breast cancer
• angina
• VTE risk

Question 10

What additional monitoring must be in place during use of topical oestrogen and why?

Answer 10

• women must be monitored at least annually with a view of stopping treatment whenever possible
• it is not known whether long term use increases the risk of endometrial hyperplasia / cancer