Vaginal dryness

Vaginal dryness is a sensation of reduced vaginal lubrication or moisture, often with irritation, burning or dyspareunia. Oestrogen deficiency is the commonest cause, and the usual presentation is the genitourinary syndrome of menopause. Other causes include medicines, breastfeeding, autoimmune disease and inadequate arousal. Vaginal dryness is under reported and does not resolve without treatment when caused by oestrogen deficiency.

Anatomy and physiology. Vaginal epithelial thickness, glycogen content and lactobacilli depend on oestrogen. Lubrication during arousal comes from a vascular transudate and minor contributions from Bartholin and Skene glands.

Atrophic changes. Oestrogen loss causes thinning of the epithelium, loss of rugae, reduced blood flow and elasticity, a rise in pH to over 5, loss of lactobacilli and a parabasal cell predominance.

Classification. Oestrogen deficient causes (natural menopause, surgical menopause, premature ovarian insufficiency, breastfeeding, antioestrogen and chemotherapy or radiotherapy treatment, hypothalamic suppression) versus oestrogen sufficient causes (arousal disorder, anticholinergic drugs, Sjögren syndrome, dermatoses, irritants, psychological factors).

Temporal patterns. Gradual after natural menopause; abrupt after oophorectomy, chemotherapy or gonadotropin releasing hormone agonists; cyclical or persistent with progestogen only contraception; transient postpartum and while breastfeeding.

History

• Dryness, burning, irritation, itching, dyspareunia, postcoital spotting, discharge.
• Urinary symptoms: urgency, frequency, dysuria, recurrent urinary tract infection.
• Prolapse symptoms and pelvic floor problems.
• Menstrual history, vasomotor symptoms, age at menopause, oophorectomy or hysterectomy, cancer treatment (tamoxifen, aromatase inhibitors, pelvic radiotherapy, chemotherapy), recent delivery and breastfeeding.
• Contraception: depot medroxyprogesterone acetate, combined hormonal, progestogen only, levonorgestrel intrauterine system.
• Drugs: antihistamines, anticholinergics, antidepressants, antiandrogens, gonadotropin releasing hormone agonists.
• Dry eyes or mouth, joint symptoms (Sjögren syndrome), diabetes, thyroid disease, eating disorder, smoking.
• Sexual function (desire, arousal, pain), relationship, trauma, mood.
• Use of soaps, douches, lubricants and moisturisers.

Examination

• Vulva: loss of labial fullness, pallor, thinning, loss of pubic hair, introital narrowing, fissures at the posterior fourchette, urethral meatus eversion or caruncle.
• Vagina: pale, smooth, dry mucosa, petechiae, loss of rugae, friability, stenosis.
• Vaginal pH on the lateral wall: over 5 supports atrophy.
• Microscopy: parabasal cells and few lactobacilli.
• Prolapse, pelvic floor tenderness and uterine size.
• Signs of Sjögren syndrome, thyroid disease and virilisation when relevant.

Red flags

• Postmenopausal bleeding or blood stained discharge.
• Persistent ulcer, plaque or mass.
• Pelvic mass or unexplained pelvic pain.
• Haematuria or weight loss.
• Amenorrhoea before age 40 (premature ovarian insufficiency).
• Galactorrhoea, headache or visual field loss (hyperprolactinaemia).

Special groups. Breast cancer survivors on tamoxifen or aromatase inhibitors (avoid or limit hormonal treatment). Postpartum breastfeeding women (transient). Premature ovarian insufficiency (systemic treatment indicated).

Organised by mechanism.

Oestrogen deficiency

• Genitourinary syndrome of menopause (natural or surgical menopause).
• Premature ovarian insufficiency.
• Lactational hypo-oestrogenism.
• Antioestrogen treatment (tamoxifen, aromatase inhibitors), gonadotropin releasing hormone agonist treatment, chemotherapy and pelvic radiotherapy.
• Hypothalamic amenorrhoea (low body weight, excessive exercise, eating disorder).
• Hyperprolactinaemia.
• Progestogen only and long acting contraception, including depot medroxyprogesterone acetate.

Oestrogen sufficient

• Medicines: antihistamines, anticholinergics, antidepressants, antiandrogens.
• Sjögren syndrome.
• Lichen sclerosus and lichen planus with scarring.
• Contact irritation from douches, soaps and spermicides.
• Female sexual arousal disorder (psychological, relational, neurological, vascular).
• Diabetes mellitus (neuropathy and vascular).
• Pelvic floor hypertonicity and provoked vestibulodynia presenting as dryness.
• Female genital cutting scarring and previous trauma.

Serious conditions presenting with dryness or dyspareunia

• Vaginal or cervical cancer and vulval intraepithelial neoplasia.
• Pelvic radiation vaginal fibrosis.

Stepwise reasoning

1. Decide whether oestrogen deficiency explains the picture from age, menstrual history, drugs and examination.
2. Exclude infection and alarm features.
3. Test for premature ovarian insufficiency under 45 years, and for other endocrine and autoimmune causes when features suggest.

Tests

• Diagnosis is clinical in postmenopausal women with typical findings. Vaginal pH over 5 and a parabasal predominance on microscopy support it.
• Swabs and amplification tests to exclude infection when discharge or ulcer is present.
• Urine pregnancy test when pregnancy is possible.
• FSH and oestradiol in women under 45 with amenorrhoea. FSH over 25 IU/L on two samples at least 4 weeks apart supports premature ovarian insufficiency; refer for confirmation, karyotype and bone density measurement.
• Prolactin and thyroid function tests for amenorrhoea or galactorrhoea.
• Anti Ro (SSA) and anti La (SSB) antibodies when dry eyes or mouth are present.
• HbA1c if diabetes is suspected.
• Transvaginal ultrasound for postmenopausal bleeding; endometrial thickness over 4 mm needs endometrial sampling.
• Cervical screening if due. Biopsy for any ulcer, plaque or irregular lesion.

Limitations. Vaginal pH is raised by blood, semen and infection. FSH is unreliable during hormonal contraception and in the perimenopause. Vaginal maturation indices are not required for diagnosis.

General measures. Stop irritants and douching. Review and, where possible, reduce anticholinergic and antihistamine drugs. Encourage regular sexual activity, with dilators if stenosis, and pelvic floor physiotherapy for hypertonicity.

Non hormonal treatment (first line for mild symptoms, and for women with hormone sensitive cancer)

• Vaginal moisturiser (hyaluronic acid or polycarbophil based) every 2 to 3 days, within the product's labelled maximum; full effect over 2 to 4 weeks.
• Water based or silicone lubricant during intercourse. Avoid oil with latex condoms.

Local oestrogen (moderate to severe symptoms, or failure of non hormonal treatment)

• Oestradiol 10 microgram vaginal tablet inserted nightly for 2 weeks, then twice weekly; maximum one tablet daily.
• Oestriol 0.5 mg vaginal pessary nightly for 3 weeks, then twice weekly.
• Oestriol 0.1% cream, one applicator (0.5 g) daily for 2 to 3 weeks, then twice weekly; maximum 0.5 g daily.
• Prasterone 6.5 mg vaginal insert nightly, where available.
• Monitoring: review at 3 months; benefit builds over 12 weeks; reassess need at least yearly. Report any vaginal bleeding for evaluation. A progestogen is not required for low dose vaginal oestrogen used as labelled.
• Contraindications: undiagnosed vaginal bleeding, active venous thromboembolism, active liver disease, and hypersensitivity. Hormone sensitive cancer needs specialist discussion.

Oral selective oestrogen receptor modulator. Ospemifene 60 mg orally once daily with food for moderate to severe dyspareunia in women who are not candidates for local oestrogen; maximum 60 mg daily; contraindicated with undiagnosed vaginal bleeding, active or past venous thromboembolism and oestrogen dependent neoplasia.

Systemic hormone therapy. Directed by the burden of vasomotor and other menopausal symptoms. Add local oestrogen if dryness persists despite systemic treatment. In premature ovarian insufficiency, give systemic hormone therapy until at least the age of natural menopause (about 51 years).

Breast cancer survivors. Start with non hormonal treatment. If symptoms persist, local oestrogen at the lowest effective dose may be considered after discussion with the oncology team. Aromatase inhibitor users may have raised serum oestradiol with some products; evidence is limited and decisions are individual.

Other causes. Treat the cause: switch depot medroxyprogesterone acetate if causing dryness, treat Sjögren syndrome, correct hyperprolactinaemia, and address psychosexual causes with counselling and sex therapy. For lichen sclerosus, use clobetasol propionate 0.05% ointment, 0.5 g to affected skin nightly for 4 weeks, then on alternate nights for 4 weeks, then twice weekly for 4 weeks.

Laser and radiofrequency treatments. Evidence is limited and they are not first line.

Monitoring. Review at 3 months. Reassess annually. Check for any new bleeding, and update cervical screening.

Referral and escalation. Refer urgently within 2 weeks for postmenopausal bleeding with endometrial thickness over 4 mm, or a vaginal lesion. Refer to endocrinology or gynaecology for premature ovarian insufficiency. Refer to oncology and menopause specialists for hormone sensitive cancer. Refer to psychosexual services for non hormonal causes. Refer to rheumatology for Sjögren syndrome.

Admission criteria. Not usually needed.

Discharge and follow up. Maintain treatment, because symptoms return when stopped.

Safety netting. Return for vaginal bleeding, persistent ulcers, mass, or pelvic pain.