Atrophic vaginitis

For patient information, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

Synonyms and keywords: Atrophic vulvovaginitis; vaginal atrophy; urogenital atrophy; genitourinary syndrome of menopause

Pathophysiology

Pathogenesis

The pathogenesis of atrophic vaginitis is due to decreased estrogen levels. Estrogen is a vasoactive hormone, which increases blood flow and maintain vaginal lubrication through fluid transudation from blood vessels. The following are the manifestations of decreased estrogen levels:

• A hypoestrogenic state, such as that seen in menopause, causes the vaginal epithelium to lose its rugae, as well as become thin and pale or erythematous with fine petechial hemorrhages.
• Decreased glycogen content within the epithelium due to decreased thickness leads to less glycogen content available for the lactobacilli to utilize and turn it into lactic acid. As a result, the vaginal pH rises with a resultant overgrowth of other bacteria, such as group B streptococci, Staphylococci and diptheroids. As a result, vaginal infections, UTI and inflammation become more common in the setting of atrophic vaginitis.

Genetics

There are no genetic factors associated with atrophic vaginitis.

Gross Pathology

Gross pathology findings in atrophic vaginitis include:

• Vaginal dryness
• Loss of vaginal rugae
• Changes in vaginal mucosa: pallor and friability or redness and petechiae of the mucosa

Causes

Atrophic vaginitis is caused by any condition that may lead to decreased circulating estrogen levels. A hypoestrogenic state may be due to ovarian failure or other causes:

• Ovarian failure: this category includes menopause, premature ovarian failure, bilateral oophorectomy, chemotherapy and radiation
• Other causes: elevated prolactin levels, due to lactation or pituitary adenoma, or medications that have an anti-estrogenic effect

Epidemiology and Demographics

• Atrophic vaginitis is often an underdiagnosed condition, because many women are embarrassed to discuss their symptoms. Some others think of the symptoms associated with atrophic vaginitis as a process of natural aging.
• Based on self-reported symptoms of vaginal dryness, the prevalence of atrophic vaginitis ranged from 4% to 47%, depending on the stage of menopause (early or late menopause).

Risk Factors

The risk factors associated with vaginal atrophy are related to decreased estrogen levels, which can be due to menopause (most common cause) or other causes that may lead to hypoestrogenism or vaginal atrophy. These include:

• Menopause (most common cause)
• Bilateral oophorectomy
• Premature ovarian failure
• Decreased ovarian function, due to chemotherapy or radiation
• Medications with an anti-estrogenic side effect:
  • Tamoxifen
  • Danazol
  • Medroxyprogesterone acetate
  • GnRH agonsists: leuprolide, nafarelin, goserelin
  • GnRH antagonists: ganirelix
• Elevated prolactin levels during lactation
• Sexual abstinence
• Vaginal nulliparity
• Smoking
• Alcohol abuse
• Lack of exercise

Screening

There are no screening recommendations for atrophic vaginitis.

Differentiating atrophic vaginitis from other diseases

Atrophic vaginitis must be differentiated from other disease processes that may present with similar symptoms. These can be divided into 4 categories:

• Vaginal infections: Candida vulvovaginitis, bacterial vaginosis and trichomoniasis
• Vulvovaginal dermatoses: lichen sclerosus, lichen planus and lichen simplex chronicus
• Cancer and precancerous lesions: vulvar intraepithelial neoplasia, vulvar cancer and extramammary Paget disease
• Others: foreign body, sexual trauma and contact irritants

Disease	Findings
Atrophic vaginitis	Progressive symptoms Presents with yellow and malodorous vaginal discharge, vaginal dryness, postcoital bleeding, and dyspareunia with the signs of vaginal inflammation and elevated vaginal pH (>5) Diagnosis is critical and laboratory tests help to confirm hypoestrogenic state
Trichomoniasis	Presents with purulent, malodorous, thin discharge associated with burning, pruritus, and dysuria, with the signs of vaginal inflammation and elevated vaginal pH (>4.5) Motile trichomonads on wet mount are demonstrated Positive culture (Gold standard) Positive nucleic acid amplification test (NAAT)
Bacterial Vaginosis	Presents with dysuria, vaginal discharge Fishy odor (positive whiff test) Normal vaginal PH (<4.5) On speculum examination signs of vaginal inflammation are demonstrated
Vaginal candidiasis	Presents with vulvar pruritus and cottage cheese-like vaginal discharge with no or minimal odor with normal vaginal pH (4-4.5) presence of Candida on wet mount (adding 10% KOH destroys the cellular elements and facilitates recognition of budding yeast, pseudohyphae, and hyphae)
Lichen Sclerosis	Hypopigmented, crinkled, waxy-appearing tissue, with coalescing ivory and pink plaques, often in butterfly or figure of eight pattern involving labia majora and minora and clitoral hood and extending around anus May result in labial agglutination
Lichen Planus	Painful, red plaques or erosions, variably with white lacy edges or violaceous borders; may extend into vagina
Lichen simplex chronicus (hyperkeratosis)	Thick, lichenified skin, often erythematous, caused by long-term rubbing or scratching
Contact dermatitis (irritant or allergic)	Redness, swelling, and itching, sometimes with blistering and painful, bright red swelling
Vulvar intraepithelial neoplasm	Red, white, or dark raised or eroded lesions, multifocal
Vulvar Cancer	Commonly solitary ulcer with raised or indurated edge
Extramammary Paget disease	Brick red, scaly, eczematoid plaque with sharply demarcated border and sometimes a roughened surface

Natural History, Complications and Prognosis

Complications

Complications of atrophic vaginitis include:

• Stress urinary incontinence
• Urge incontinence
• Pelvic organ prolapse
• Recurrent urinary tract infections
• Sexual dysfunction

Diagnosis

History and Symptoms

Symptoms of atrophic vaginitis can be divided into three categories:

• External genital symptoms:
  • Vaginal dryness
  • Vaginal irritation
  • Vaginal itching
  • Vaginal discharge

• Sexual symptoms:
  • Painful sexual intercourse (dyspareunia)
  • Postcoital bleeding
  • Loss of bleeding
  • Loss of arousal
  • Pelvic pain

• Urological symptoms:
  • Burning on urination (dysuria)
  • Urinary frequency
  • Urinary urgency
  • Nocturia
  • Urinary incontinence
  • Recurrent urinary tract infections (UTI)

Physical Examination

Physical examination in women with atrophic vaginitis includes a general inspection of the external genitalia, as well as a speculum examination of the internal genitalia.

• Physical examination in women with atrophic vaginitis begins with inspection of the external genitalia. Findings include decreased elasticity of the skin, sparsity of pubic hair, dryness of the labia and/or fusion of the labia minora.
• Gynecologic examination is carried using a small speculum to avoid damage to the atrophic vaginal or vulvar tissue. Vaginal epithelium may be atrophic and appear pale, smooth and shiny, or it may be inflamed, with patchy erythema, petechiae and increased friability.
• Other findings may include: pelvic organ prolapse, such as cystocele and/or rectocele, urethral polyps or eversion of the urethral mucosa.

Ultrasound

An ultrasound of the uterus may demonstrate thinning of the endometrium lining to 4-5mm.

Treatment

Medical Therapy

The mainstay of treatment of atrophic vaginitis is medical therapy. It can be categorized into two groups:

• Nonhormonal therapy: this includes vaginal moisturizers and lubricants
• Hormonal therapy: this includes vaginally administered local estrogens, which can be in the form of cream, ring or tablet

References

Template:Diseases of the pelvis, genitals and breasts