Atrophic vaginitis often occurs in post-menopausal women. It is characterised by inflammation and thinning of the vulvovaginal tissue due to a decline in oestrogen levels. It is a genitourinary syndrome of menopause.
Pathophysiology
Normally the epithelial lining of the vagina and urinary tract in females responds to oestrogen by becoming thicker and producing lubricating secretions. However, as women enter menopause and oestrogen levels begin to decline, so does the thickness of the vaginal mucosa. It also becomes dry which makes it prone to inflammation.
This is accompanied by an alteration in the vaginal pH and microflora → increased infections.
As oestrogen is valuable in its role in maintaining healthy connective tissue in the pelvis, a lack of oestrogen also can lead to pelvic organ prolapse and stress incontinence.
😷 Presentation
- Thin and pale vaginal mucosa
- Vaginal dryness and itching
- Dyspareunia - pain during sex.
- Post-coital bleeding
- Discharge - this is due to the inflammation.
- Loss of vaginal rugae and loss of pubic hair
- pH >4.5
🔍 Investigations
🥇 We can do a clinical examination including speculum exam to look for signs of vaginal atrophy (as mentioned above).
💡 A transvaginal ultrasound and endometrial biopsy must be done to exclude any endometrial cancer. Atrophic vaginitis is a diagnosis of exclusion after ruling out something more sinister.
If there is discharge, it may be assessed for infection with an infection screen
Vaginal pH testing - pH >4.5
🧰 Management
Systemic HRT may be considered, but even topical oestrogen preparations can make a big difference. The options for HRT include:
- Estriol cream
- Estriol pessaries
- Estradiol tablets - vagifem is taken OD.
- Estradiol ring - estring. Replaced once every 3 months.
Systemic oestrogen has many contraindications and risks such as breast cancer, angina and VTE. Topical oestrogen also shares these risks and contraindications. Therefore women need to be reviewed annually.
- Moisturisers
- 🥇 Lubricants - provide short-term improvement and alleviate symptoms such as dyspareunia and itching.
- Sylk
- Replens
- YES
🚨 Complications
- Recurrent UTI
- Stress incontinence
- Pelvic organ prolapse