Background

Atrophic vaginitis is ‘inflammation of the vagina due to thinning and decreased lubrication of the tissues caused by low oestrogen levels.’ It is also known as vaginal atrophy or urogenital atrophy.

 

This chronic and progressive condition is most commonly seen in post-menopausal women but it can occur in women who have had their ovaries removed, women who have taken anti-oestrogenic treatments (e.g tamoxifen) or women who have received chemotherapy or radiotherapy. Also it can affect women who are postpartum or breastfeeding because of their low oestrogen levels.

 

Atrophied vagina's can become further inflamed by perfumed soaps, washing detergents, lotions and vaginal deodorants.    

History

The presenting symptoms of atrophic vaginitis can be very variable and some women may be asymptomatic because it takes 5-10 years after the menopause for the atrophic changes to affect most women. The atrophic changes can affect the vagina and the urinary tract because of their common embryologic origin therefore women may present complaining of genital and urinary symptoms.

 

Postcoital bleeding may occur in menopausal or postmenopausal women with atrophic vaginitis because the vagina is not adequately lubricated due to reduced mucosal secretions. NICE referral guidelines recommend that every woman presenting with postcoital bleeding should have a full pelvic examination and speculum examination of the cervix and an urgent referral is required if any features characteristic of cervical cancer are present.

Examination

It is paramount to remember that performing a PV examination on a woman who suffers from atrophic vaginitis can be very uncomfortable or painful for the patient. A well lubricated, small speculum should be used to minimise discomfort for the patient and to avoid injury to the atrophic tissues. Examination may reveal a dry vagina with decreased vaginal folds and thin, pale mucosa. The vagina may have lost its elasticity and be shorter in depth because of prolapse formation.  

Investigations

Management

Vaginal symptoms

Hormone replacement therapy (HRT) will provide oestrogen replacement and hence decrease the symptoms caused by lack of oestrogen. It can be taken in systemic form or topical (creams, pessaries, tablets, vaginal ring.) Non-hormonal vaginal moisturisers and lubricants can benefit women who suffer from vaginal dryness. These treatments are suitable for women who wish not to take HRT or for women who have medical contraindications.

 

Urinary symptoms

The Royal College of Obstetricians and Gynaecologists suggest that HRT will decrease urinary symptoms (e.g urgency) and help reduce stress incontinence. They also report that topical HRT may reduce recurrent urinary tract infections.    

Sexual activity

Many women suffering from atrophic vaginitis complain of pain during intercourse but it is important to encourage patients to continue to be sexually active. It is thought that intercourse improves blood circulation to the vagina and helps maintain and repair tissues. Also, the lubricative response to stimulation will counteract the vaginal dryness. A negative relationship has been found to exist between coital activity and vaginal atrophy.

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