Atrophic vaginitis

• 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. 
• Pathophysiology:

  • 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
  • Mucosa becomes thinner, less elastic and more dry
  • Tissue is more prone to inflammation
  • Also changes in the vaginal pH and microbial flora that can contribute to localised infections
  • Oestrogen also helps maintain healthy connective tissue around the pelvic organs - menopause can lead to pelvic organ prolapse and stress incontinence
• Presentation:

  • Itching
  • Dryness
  • Dyspareunia
  • Bleeding due to localised inflammation
  • Should consider atrophic vaginitis in older women presenting with recurrent UTIs, stress incontinence or pelvic organ prolapse
• Examination:

  • pale mucosa
  • Thin skin
  • Reduced skin folds
  • Erythema and inflammation
  • Dryness
  • Sparse pubic hair
• Management:

  • Vaginal lubricants for dryness - Sylk, Replens and YES
  • Topical oestrogen:
  • Estriol cream - applied using syringe at bedtime
  • Estriol pessaries - inserted at bedtime
  • Estradiol tablets - Vagiferm
  • Estradiol ring - replaced every 3 months
• Topical oestrogens:

  • Share many contraindications with systemic HRT such as breast cancer, angina and VTE
  • Unclear whether long term use increases risk of endometrial hyperplasia and endometrial cancer
  • Should be monitored at least annually