Atrophic Vaginitis After Menopause

Overview of Postmenopausal Atrophic Vaginitis

Postmenopausal atrophic vaginitis, or vaginal atrophy, is the thinning of the vaginal walls caused by decreased estrogen levels. This most often occurs after menopause.

Menopause is the time in a woman’s life, usually between the ages of 45 and 55, when her ovaries no longer release eggs. It also stops menstrual periods. A woman is postmenopausal when she has not been for 12 months or longer.

Women with vaginal atrophy are more likely to have chronic vaginal infections and urinary function problems. It can also make sexual intercourse painful.

Vaginal Atrophy Symptoms

Although vaginal atrophy is common, only 20 to 25 percent of symptomatic women seek medical advice from their doctor.

In some women, symptoms appear in perimenopause or in the years leading up to menopause. In other women, symptoms may not appear for years, if at all.

Symptoms may include:

  • thinning of the vaginal walls
  • Shortening and tightening the vaginal canal
  • Lack of vaginal moisture (vaginal dryness)
  • Vaginal burning (inflammation)
  • spotting after intercourse
  • discomfort or pain during intercourse
  • Pain or burning with urination
  • More frequent urinary tract infections
  • urinary incontinence (involuntary leakage)

Causes of Vaginal Atrophy

The cause of atrophic vaginitis is a decrease in estrogen. Without estrogen, vaginal tissue thins and dries up. It becomes less elastic, more fragile and more easily injured.

A drop in estrogen can occur at times other than menopause, including:

  • During breastfeeding
  • After removal of the ovaries (surgical menopause)
  • After chemotherapy for cancer treatment
  • After pelvic radiation therapy for cancer treatment
  • Post hormonal therapy for breast cancer treatment

Regular sexual activity helps keep vaginal tissues healthy. A healthy sex life also benefits the circulatory system and improves heart health.

Risk Factors for Vaginal Atrophy

Some women are more likely than others to have atrophic vaginitis. Women who do not give birth vaginally are more prone to vaginal atrophy than women who deliver their babies vaginally.

Smoking impairs blood circulation, destroys the vagina and other oxygen tissues. Tissue thinning occurs when blood flow is reduced or restricted. Smokers are also less responsive to estrogen therapy in pill form.

Potential Complications

Atrophic vaginitis increases a woman’s risk of contracting vaginal infections. Atrophy causes changes in the acidic environment of the vagina, making it easier for bacteria, yeast, and other organisms to thrive.

It also increases the risk of urinary tract atrophy (genitourinary atrophy). Symptoms associated with urinary tract problems due to atrophy include more frequent or more urgent urination or a burning sensation during urination.

Some women may have incontinence and have more urinary tract infections.

Diagnosing Vaginal Atrophy

See your doctor right away if intercourse is painful, even with lubrication. You should also see your doctor if you experience unusual vaginal bleeding, discharge, burning, or pain.

Some women are embarrassed to talk to their doctors about this intimate problem. If you are experiencing these symptoms, it is important to seek advice from a doctor to help avoid the potential complications outlined above.

Your doctor will ask you questions about your health history. They will want to know how long ago you stopped having periods and whether you have cancer. The doctor may ask about the product you use (if any), commercial or over-the-counter products. Some perfumes, soaps, bath products, deodorants, lubricants and spermicides can aggravate sensitive genitals.

Your doctor may refer you to a gynecologist for tests and a physical exam. During a pelvic exam, they will palpate or feel your pelvic organs. The doctor also examines your external genitalia for physical signs such as atrophy:

  • Pale, smooth, shiny vaginal skin
  • loss of flexibility
  • sparse pubic hair
  • stretching of uterine tissue
  • Pelvic organ prolapse (bulges in the walls of the vagina)

The doctor may order the following tests:

  • pelvic exam
  • Vaginal smear test
  • Vaginal acidity test
  • Blood test
  • Urine test

The smear test is a microscopic examination that is scraped from the vaginal walls. It looks for certain types of cells and bacteria that are more common with vaginal atrophy.

A paper indicator strip is inserted into the vagina to test for acidity. Your doctor may also collect vaginal secretions for this test.

You may also be asked to provide blood and urine samples for laboratory testing and analysis. These tests check for several factors, including your estrogen levels.

Vaginal Atrophy Treatment

With treatment, it is possible to improve your vaginal health and quality of life. Treatment may focus on the symptoms or the underlying cause.

Over-the-counter moisturizers or water-based lubricants can help treat dryness.

If symptoms are severe, your doctor may recommend estrogen replacement therapy. Estrogen increases vaginal elasticity and natural moisture. It usually works in just a few weeks. Estrogen can be taken topically or orally.

Topical Estrogen

Removing estrogen through the skin limits how much estrogen enters the bloodstream. Topical estrogens do not treat any systemic symptoms of menopause, such as hot flashes. These estrogen treatments have not been shown to increase the risk of endometrial cancer. However, if you are using topical estrogen and experience unusual vaginal bleeding, call your doctor right away.

Topical estrogen is available in several forms:

  • A vaginal estrogen ring like Estring. The prediction is a flexible, soft ring that is inserted into the upper part of the vagina by your doctor. It delivers a fixed dose of estrogen and only needs to be changed every three months. Estrogen rings are higher-dose estrogen preparations and may increase a woman’s risk of endometrial cancer. You should talk to your doctor about your risk and possible needs for progestin.
  • A vaginal estrogen cream such as Premarin or Estrace. This type of medication is inserted into the vagina with an applicator at bedtime. Your doctor may prescribe the cream daily for a few weeks, then go down two or three times a week.
  • A vaginal estrogen tablet, such as Vagifem, is inserted into the vagina using a disposable applicator. Usually, a daily dose is prescribed first, which is then tapered down to once or twice a week.

Oral Estrogen

During menopause, oral estrogen is often used to treat hot flashes and vaginal dryness. But long-term use increases the risk of certain cancers. Oral estrogen is not usually prescribed to people with cancer.

If your health history does not include cancer, progesterone may be given in addition to estrogen in pill or patch form. Your doctor will work with you to decide which option is best for you.

Women taking progesterone and estrogen may have some bleeding after menopause. While the risk of cancer is minimal for women taking both progesterone and estrogen, you should still see your doctor to evaluate for episodes of post-menopausal bleeding. This may be an early sign of endometrial cancer.

Prevention and Lifestyle

In addition to taking medication, you can also make some lifestyle changes.

Wearing cotton underwear and loose-fitting clothing can improve symptoms. Loose cotton clothing improves air circulation around the genitals, thus creating a less ideal environment for bacteria to breed.

A woman with atrophic vaginitis may experience pain during intercourse. However, staying sexually active increases blood circulation in the vagina and stimulates natural moisture. Sexual activity has no effect on estrogen levels. But by improving blood circulation, it keeps your genitals healthier for longer. Giving time to be sexually aroused can make intercourse more comfortable.

Vitamin E oil can also be used as a moisturizer. There is also some evidence that vitamin D increases vaginal moisture. Vitamin D also helps the body absorb calcium. This helps slow or prevent postmenopausal bone loss, especially when combined with regular exercise.

Resources:

Bachmann, GA, et al. (2000). Diagnosis and treatment of atrophic vaginitis.

Barbieri, RL, et al. (2015). Menopausal hormone therapy: benefits and risks.

Chlebowski, RT et al. (2015). Breast cancer after estrogen-only plus progestin and estrogen use: analysis of data from 2 women’s health intervention randomized clinical trials. DOI:

Mayo Clinic Staff. (2016). Vaginal atrophy.

Menopausal hormone therapy and cancer risk. (2015).

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