Vaginal Dryness

Vaginal dryness is a feeling of insufficient moisture in the vagina, causing discomfort, itching and painful intercourse.

• A common cause is oestrogen deficiency at menopause, after childbirth or during breastfeeding.
• Other causes are anti-oestrogen cancer drugs, hormonal contraception, antihistamines, antidepressants, radiotherapy, Sjögren syndrome, smoking and inadequate arousal.
• Treatment is by lubricants, moisturisers and local oestrogen.

Dryness, burning, itching, dyspareunia, post-coital spotting and urinary symptoms.

• Pale, thin, dry vaginal mucosa; reduced lubrication and rugae; vaginal pH above 5 in oestrogen deficiency.
• Differential diagnosis: atrophic vaginitis, vulvovaginal candidiasis, lichen sclerosus, lichen planus, contact dermatitis, vaginismus, vulvodynia, diabetes.
• Complications: dyspareunia, urinary tract infection, fissures, sexual dysfunction.

Diagnosis is clinical, with exclusion of infection and other causes.

• History of menopause, breastfeeding, drugs and sexual function.
• Speculum examination and vaginal pH.
• Wet mount for parabasal cells and exclusion of infection.
• Random blood glucose.
• Postmenopausal bleeding needs ultrasound for endometrial thickness (above 4 mm needs sampling).

Use lubricants and moisturisers first, adding local oestrogen when needed.

• Supportive: water-based or silicone lubricant at every intercourse; vaginal moisturiser (polycarbophil gel) 2 to 3 times weekly; adequate foreplay; stop smoking; avoid soaps, douching and perfumed products; adjust or stop drugs causing dryness where possible.
• Pharmacological: oestriol 0.1 percent cream 0.5 g intravaginal nightly for 2 weeks then twice weekly, or oestradiol 10 micrograms vaginal tablet daily for 2 weeks then twice weekly. Reassess need yearly. Treat associated candidiasis with clotrimazole 500 mg pessary single dose.
• Procedures: none.
• Special groups: in breastfeeding women use lubricants and moisturisers, and local oestrogen only if symptoms persist after weaning has been considered. In women with breast cancer or on tamoxifen use non-hormonal products first. Contraindications to oestrogen are undiagnosed bleeding, active hormone-dependent cancer and acute thrombosis.
• Red flags: postmenopausal bleeding, vulval ulcer or white plaque, haematuria, pelvic mass.
• Follow-up: review at 3 months for response, then yearly.