Atrophic vaginitis Flashcards
Define atrophic vaginitis
vaginal irritation caused by irregular thinning of the vaginal epithelium
Aetiology of atrophic vaginitis
Menopause (reduction in circulation oestrogen)
Lactation (Especially prolonged)
Hyperprolactinaemia
High-dose progesterone medicines
Breast cancer medication, such as tamoxifen and aromatase inhibitors
What are the symptoms of atrophic vaginitis
Vaginal or vulval: Irritation | Dryness | Itching | Burning
Dyspareunia
Skin splitting (fissuring) at the entrance to the vagina (posterior fourchette)
Vaginal spotting (bleeding)
Dysuria, Urinary urgency/frequency, incontinence
What are the differentials for atrophic vaginitis
Candidiasis
Bacterial vaginosis
Trichomoniasis
Gonorrhoea
Chlamydia
Lichen planus
Lichen sclerosis
Irritant reaction
UTI
Malignancy
What are the signs of atrophic vaginitis on examination
Vaginal/vulval examination
Vulva appears paler
Labia are thinner and smaller
Clitoral hood is less obvious
A red cell membrane or polyp may be visible at urethral opening
The vaginal skin looks thin or dry, with tiny blood vessels under it resulting in patchy
Stretching the vulva may cause splitting of the skin at the bottom of the vagina - cracks or fissures
Loss of rugal folds
What investigations should be done for atrophic vaginitis
Atrophic vaginitis is a diagnosis of exclusion (clinical)
Endometrial cancer must be ruled out, and the first line investigation for this is always TVUSS.
Bedside: vaginal pH testing, endocervical swab (rule out BV)
Bloods: OGTT (uncontrolled DM may contribute)
OtherL TVUSS, vaginal cytology
What is the first line management for atrophic vaginitis
Non-hormonal
Hygiene: Use a non-soap cleanser or gently wash with warm water alone, no more than twice daily
Emollient cream suitable for sensitive skin or petroleum jelly if the vulva feels dry or itchy
Lubricant for sexual intercourse – if it stings, try another or use an oil or petroleum jelly
Vaginal moisturer trial
Review medications: consider stopping any Anticholinergic, antihistamine, decongestant or antidepressant - medication may be contributing to dryness
Topical steroid short-term may be necessary for dermatitis caused by irritants such as urine, panty liner or tight clothing
What is the second line management for atrophic vaginitis
Hormonal - topical oestrogen
Either vaginal cream, pessaries, or vaginal ring
Results in normalisation of vaginal walls, improved blood flow, reduced pH, re-colonisation by lactobacilli etc.
What are the side effects of topical oestrogen use for atrophic vaginitis
Vaginal itching and burning
Increased risk of vaginal Candida albicans infection (vaginal thrush)
Breast discomfort/pain (uncommon)
Vaginal bleeding (rare).
Progression of existing oestrogen-dependent cancers
What are the complications of atrophic vaginitis
Recurrent genitourinary infections
Vaginal pelvic discomfort and pain
Reduced QOL
What is the prognosis for atrophic vaginitis
Treatment gives significant symptomatic relief
