Postpartum Vulvovaginal Dryness

Postpartum vulvovaginal dryness is a feeling of dryness, burning, itching or tightness of the vulva and vagina in the months after birth, caused mainly by low oestrogen in breastfeeding. It affects 40 to 70 percent of breastfeeding women at 3 months, and lasts until the menstrual cycle returns or breastfeeding is reduced. It matters because it causes painful intercourse, irritation and a higher risk of infection, and simple treatment helps.

• Risk factors: breastfeeding, progestogen-only pill, depot medroxyprogesterone, levonorgestrel intrauterine system in some, perineal tears, smoking, stress, low body weight.
• Oestrogen levels return to normal 6 to 8 weeks after breastfeeding stops.
• Symptoms often go unreported.

Women have vaginal dryness, burning, itching, irritation, pain with intercourse, light spotting after sex and sometimes urinary frequency or urgency. The vaginal skin looks thin, pale and dry with reduced folds.

• Reduced lubrication during arousal.
• Fissures at the fourchette in severe cases.
• Differential diagnosis: vulvovaginal candidiasis, bacterial vaginosis, contact dermatitis, lichen sclerosus, vestibulodynia, perineal scar pain, sexually transmitted infection, diabetes, thyroid disease.
• Complications: dyspareunia, vaginal infections, urinary tract infection, fissures and bleeding, loss of desire, relationship strain.

The approach is history and examination, with tests to exclude infection.

• Symptoms, breastfeeding pattern, contraception, soaps and products used, recent infection or tears.
• Examination: vulval and vaginal skin colour, thickness and moisture; scar tenderness; fissures; discharge.
• Vaginal pH (above 5.0 suggests low oestrogen or infection), high vaginal swab for candidiasis and bacterial vaginosis, chlamydia and gonorrhoea tests where indicated.
• Fasting glucose and thyroid function if symptoms are marked or persist.

The principle is moisturisers and lubricants first, with low dose vaginal oestrogen for persistent symptoms and treatment of any infection.

• Supportive: avoid soaps, perfumed products and douching; wash with water or a plain emollient; cotton underwear; water based lubricant at each intercourse (avoid oil based products with condoms); adequate fluids; advise that symptoms resolve after weaning; review contraception.
• Pharmacological: vaginal moisturiser (hyaluronic acid gel or polycarbophil) applied every 3 days; vaginal oestradiol 10 micrograms tablet at night for 2 weeks then twice weekly for 3 months, or oestriol 0.1 percent cream 0.5 g nightly for 2 weeks then twice weekly, using the lowest effective dose and starting after 6 weeks in breastfeeding women; clotrimazole 500 mg vaginal pessary once for candidiasis; metronidazole 400 mg oral 12-hourly for 7 days for bacterial vaginosis; hydrocortisone 1 percent cream applied to the vulva 12-hourly for up to 7 days for dermatitis.
• Procedures: none.
• Special groups: women on depot medroxyprogesterone or the progestogen-only pill with severe dryness are offered a change to a copper intrauterine device or another method; women with a personal history of breast cancer avoid vaginal oestrogen and use moisturisers only.
• Red flags: bleeding after sex that persists, white plaques with scarring, ulcers, a mass, foul discharge, severe pain, fever.
• Follow-up: review at 3 months; reassess after weaning; referral to a gynaecologist if symptoms persist at 6 months after stopping breastfeeding.