Atrophic Vaginitis - Introduction

Atrophic vaginitis (also known as vaginal atrophy, senile vaginal atrophy or urogenital atrophy) is inflammation of the vagina due to the thinning and shrinking of the vaginal epithelium ('skin').

At the menopause, the ovarian output of the female hormone oestrogen falls. One of the functions of oestrogen is to keep the vaginal healthy. Surface cells are rich in glycogen and when they are shed they result in the vagina being acidic and therefore hostile to many bacteria.

Up to 40 percent of postmenopausal women have symptoms associated with atrophic vaginitis. The thinned vaginal 'skin' predisposes the vagina and urinary tract to infection and mechanical weakness. The earliest symptoms are decreased vaginal lubrication, followed by other vaginal and urinary symptoms. Once other causes of symptoms have been eliminated, treatment usually depends on estrogen replacement. Oestrogen replacement may be provided systemically (orally, transdermally or sub-dermally - under the skin by an implant) or locally as a cream or vaginal tablet, but the dosage and delivery method must be individualised. Vaginal moisturizers and lubricants by assist with intercourse.

What is atrophic vaginitis?

  • Atrophy is the partial or complete wasting away of body tissue.
  • Vaginitis is inflammation of the vagina.

Below and to the right is a picture showing the typical changes of atrophic vaginitis. The vaginal epithelium (surface) is thin, dry and red.

The cervix may also show atrophic changes - atrophic cervicitis.

What local genital symptoms might be associated with the menopause?

After the menopause, as a result of vaginal atrophy due to loss of estrogen, vaginal dryness and discomfort are more likely to become a problem for you. Local infection, atrophic vaginitis, becomes more common now that there is less protective lactic acid and this may result in inflammation causing soreness and discharge. Some women experience severe debilitating discofort or pain.

The vaginal dryness and inflammation may cause discomfort or even pain when you make love (dyspareunia). On occasion, the inflammation may cause bleeding. All post menopausal bleeding must be investigated (17). Despite the prevalence of symptoms, only 20 to 25 percent of symptomatic women seek medical advice and  health care workers, including doctors and nurses should aim to improve the urogenital health and quality of life of a large patient population through identification and intervention in this often overlooked and under-diagnosed condition.

The peri menopause symptoms associated with atrophic vaginitis are:-

These atrophic vaginitis symptoms can occur as pre menopause symptoms although they are more common in post menopausal women.

Diagnosis of Atrophic Vaginitis

The symptoms are common and the above typical signs generally confirm the diagnosis. It is wise to exclude bacterial infections by sending a swab sample taken from high in the vagina - high vaginal swab (HVS).

How can atrophic vaginitis - dry vagina at menopause - painful sex - be treated?

If there are other accompanying menopausal symptoms including hot flushes (USA flashes) or night sweats then systemic HRT may be considered. Topical oestrogen (creams and pessaries) are commonly used in postmenopausal women to improve the quality of the vaginal epithelium in atrophic vaginitis.

Fifteen percent of premenopausal women, 10-40% of postmenopausal women, and 10-25% of women receiving systemic hormone therapy experience urogenital atrophy.

The most common symptoms are dryness, burning, pruritus, irritation, and dyspareunia (painful sexual intercourse). Topical Estrogen or hormone replacement therapy (ERT-HRT) is the treatment of choice in postmenopausal women.0101

If genital symptoms, such as vaginal dryness, pain during lovemaking or perhaps bladder symptoms are troubling you, these could be due to reduced oestrogen levels in the tissues around the genital area. These symptoms usually respond to HRT or to topical preparations (oestrogen creams or pessaries).

On occasion, local symptoms may fail to respond to HRT anyway and additional topical oestrogen may be required.

To begin with, the creams or pessaries are introduced each night for ten days to two weeks and then reduced to a maintenance regime varying from twice weekly to perhaps no more than once each month depending on symptoms, age and response. There are a variety of topical oestrogen preparations (Table 28.1).

Estring (Pharmacia and Upjohn), a synthetic soft rubber ring which slowly releases oestradiol can be introduced into the vagina and replaced at three monthly intervals. If the uterus is still present intermittent courses of progestogen should be considered to encourage endometrial shedding (HRT and progestogen). The ring is as effective as oestrogen creams and some women find the ring more acceptable.

Atrophic vaginitis is a chronic condition. It responds to oestrogen replacement but if the treatment is discontinued, it will recur. Some gynaecologists recommend a small dose of oestrogen replacement two to four times each month long-term to prevent symptoms recurring.

Table 28.1 Topical creams and pessaries that are commonly used in menopause treatment.

Preparation

Oestrogen

Company

Ortho-Gynest Pessaries Oestriol 500 g Janssen-Cilag
Ortho-Gynest Cream Oestriol  0.01% Janssen-Cilag
Ovestin Cream Oestriol 0.1% Organon
Ovestin Pessaries Oestradiol 1mg Organon
Premarin  Cream Conjugated oestrogens 625 mg Wyeth
Vagifem Pessaries Oestradiol 25 microg Novo Nordisk
Estring Ring Oestradiol (7.5 microg release/day) Pharmacia and Upjohn

Almost invariably, unless you are taking HRT, there will be some degree of vaginal atrophy after the menopause.

Quite frequently, patients are referred with vaginal discomfort and a physical examination reveals a prolapse (1). The only way to determine how much of the discomfort is due to the vaginal atrophy and how much to the prolapse is to treat the atrophy with topical (local cream or pessary) oestrogen and then reassess the symptoms.

Related Medical Abstracts - Click on the paper title:-

Restoration of vaginal ph - Rephresh

Please see Rephresh

See Also

Premarin Cream

Vagifem

Women's Health


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This is the personal website of David A Viniker MD FRCOG, retired Consultant Obstetrician and Gynaecologist - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.
I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.

I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.

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