Atrophic Vaginitis

Atrophic vaginitis, now called genitourinary syndrome of menopause, is thinning, dryness and inflammation of the vaginal and vulval tissues from oestrogen deficiency.

• It follows menopause, bilateral oophorectomy, breastfeeding, pelvic radiotherapy and anti-oestrogen treatment.
• Symptoms are progressive and do not resolve without treatment.
• Local oestrogen treats vaginal symptoms effectively with minimal systemic absorption.

Vaginal dryness, burning, itching, dyspareunia, dysuria, urinary frequency, recurrent urinary tract infection and post-coital spotting.

• Pale, thin, dry vaginal mucosa with loss of rugae, petechiae, narrowed introitus and shortened vagina.
• Vaginal pH above 5.
• Differential diagnosis: lichen sclerosus, lichen planus, vulvovaginal candidiasis, aerobic vaginitis, contact dermatitis, vulval intraepithelial neoplasia, vulvodynia.
• Complications: dyspareunia, urinary tract infection, postmenopausal bleeding, fissures, prolapse symptoms and sexual dysfunction.

Diagnosis is clinical.

• Vaginal pH above 5; wet mount with parabasal cells and few lactobacilli.
• Urine dipstick and culture when urinary symptoms are present.
• Speculum examination to exclude discharge and bleeding from the cervix or endometrium.
• Pelvic ultrasound for endometrial thickness, with endometrial sampling when there is postmenopausal bleeding and the endometrium is thicker than 4 mm.
• Biopsy of any white, ulcerated or raised vulval area.

Local oestrogen is first-line treatment, supported by lubricants and moisturisers.

• Supportive: water-based or silicone lubricants during intercourse; vaginal moisturiser (polycarbophil gel) 2 to 3 times weekly; regular sexual activity or vaginal dilators; avoid soaps and douching.
• Pharmacological: first line is vaginal oestradiol 10 micrograms tablet or pessary inserted daily for 2 weeks then twice weekly, or oestriol 0.1 percent cream 0.5 g intravaginal nightly for 2 weeks then twice weekly. Use the lowest effective dose for as long as symptoms persist, with review of the need every 12 months. Systemic hormone therapy is for women with vasomotor symptoms: oestradiol 1 mg oral daily with micronised progesterone 200 mg oral nightly for 12 days each month if the uterus is present. Treat superimposed candidiasis with clotrimazole 500 mg pessary single dose. Treat urinary tract infection with nitrofurantoin modified-release 100 mg oral 12-hourly for 5 days.
• Procedures: none.
• Special groups: in women with breast cancer use non-hormonal moisturisers and lubricants first, and local oestrogen only after specialist advice; in women with a history of venous thromboembolism, local low-dose oestradiol is acceptable after specialist advice. Absolute contraindications to oestrogen are undiagnosed vaginal bleeding, active hormone-dependent cancer and acute thrombosis. In women on tamoxifen avoid local oestrogen unless specialist input approves.
• Red flags: postmenopausal bleeding, vulval ulcer or white plaque, haematuria, pelvic mass.
• Follow-up: review at 3 months for response, then every 12 months.