Atrophic Vulvovaginitis

Atrophic vulvovaginitis is a condition where the tissues of the vagina and vulva become thinner, drier, and inflamed due to lower levels of estrogen in the body. While very common after menopause, many women suffer in silence without seeking help, even though effective treatments are available.

Table of contents

• What is Atrophic Vulvovaginitis?
• Other Names for This Condition
• Medical Classification Codes
• What Causes Atrophic Vulvovaginitis?
• Signs and Symptoms
• Parts of the Body Affected
• How is it Diagnosed?
• Treatment Options
• Prevention and Self-Care

What is Atrophic Vulvovaginitis?

Atrophic vulvovaginitis is a condition where the lining of the vagina and the skin of the vulva become thinner, drier, and more easily irritated^[1]. The condition occurs when the body produces less of a hormone called estrogen, which normally keeps these tissues healthy, thick, and moist^[2]. When estrogen levels drop, the vaginal walls thin out, produce less natural moisture, and become more fragile^[3].

This condition is extremely common. At least half of all women who go through menopause experience symptoms of atrophic vulvovaginitis^[2]. Some studies suggest that between 40% and 85% of postmenopausal women are affected^[7][17]. The condition is also known by the newer medical term genitourinary syndrome of menopause (or GSM), which describes both the vaginal and urinary symptoms that can occur together^[1][2].

Despite how common it is, only about 20 to 25 percent of women with symptoms seek medical help^[4][7]. Many women feel embarrassed to discuss these symptoms with their doctor, or they mistakenly believe that discomfort is just a normal part of aging^[1][14].

Other Names for This Condition

Atrophic vaginitis, Vaginal atrophy, Vulvovaginal atrophy, Senile vulvovaginitis, Genitourinary syndrome of menopause (GSM), Urogenital atrophy

Medical Classification Codes

N95.2; N36.2; N34.2

What Causes Atrophic Vulvovaginitis?

The main cause of atrophic vulvovaginitis is a decrease in estrogen levels in the body^[3]. Estrogen is a hormone that plays a vital role in keeping the tissues of the vagina and vulva healthy, well-lubricated, and elastic^[6]. When estrogen levels drop significantly, the tissues begin to change. They become thinner, drier, and less able to protect themselves from irritation and infection^[4].

The most common reason for decreased estrogen is menopause, the natural transition in a woman’s life when the ovaries stop producing estrogen^[4]. After menopause, estrogen levels drop dramatically, from greater than 120 pg per mL to around 18 pg per mL^[4]. This leads to many changes in the vaginal tissues, including loss of thickness, reduced elasticity, and less natural moisture^[2].

However, menopause is not the only cause. Estrogen levels can also decrease in other situations, including^[2][3][4]:

• Breastfeeding, when the body produces less estrogen naturally
• Surgical removal of both ovaries
• Radiation therapy or chemotherapy for cancer treatment
• Medications that lower estrogen levels, such as tamoxifen (used to treat breast cancer), danazol, leuprolide, nafarelin, or high-dose progesterone medicines
• Certain immune disorders
• Some birth control pills
• Premature menopause (menopause before age 40)

Smoking cigarettes can make symptoms worse, as smoking decreases estrogen levels and increases the risk of developing vaginal atrophy^[2][8]. Women who have less frequent sexual activity may also be at higher risk of more severe symptoms^[2].

When estrogen levels are low, other important changes happen in the vagina. The natural acid balance changes, making the vagina less acidic. Normally, the vagina has a pH level between 3.5 and 4.5, which helps protect against infections^[4]. When estrogen drops, the pH rises to 4.6 or higher, and the types of bacteria living in the vagina change^[3][7]. Healthy bacteria called lactobacilli decrease, and other bacteria increase, making infections more likely^[3][4].

Signs and Symptoms

Atrophic vulvovaginitis causes a range of uncomfortable symptoms that can significantly affect quality of life and intimate relationships. Symptoms typically develop slowly over time. A woman may not notice any problems until five to ten years after menopause begins^[6]. The earliest symptom is usually decreased vaginal lubrication or dryness, which may first be noticed during sexual activity^[2][4].

Common vaginal and vulvar symptoms include^[1][2][3]:

• Vaginal dryness
• Burning sensation in the vagina
• Itching in the vagina or around the vulva (external genital area)
• Painful sexual intercourse (called dyspareunia)
• Decreased lubrication during sexual activity
• Light bleeding or spotting, especially after intercourse
• Unusual vaginal discharge (often yellow in color)
• Soreness or discomfort in the genital area
• Skin splitting or cracking, especially at the entrance to the vagina

Many women with atrophic vulvovaginitis also experience urinary symptoms, which is why the condition is now called genitourinary syndrome of menopause^[1][2]. These urinary symptoms include^[1][2][3]:

• Frequent need to urinate
• Urgent need to urinate
• Burning or pain when urinating (called dysuria)
• Inability to hold urine (urinary incontinence)
• Recurrent urinary tract infections (UTIs)
• Blood in the urine

Physical changes in appearance are also common. The vulva may appear paler in color. The labia (the lips of the vulva) become thinner and smaller. The vaginal lining looks thin and dry, with small blood vessels visible underneath, which can cause patchy redness^[3]. The vaginal canal itself may become shorter and tighter^[1]. There may also be reduced pubic hair^[17].

Parts of the Body Affected

• Vagina
• Vulva (external female genitals)
• Labia (vaginal lips)
• Urethra (tube that carries urine out of the body)
• Bladder
• Pelvic floor muscles

How is it Diagnosed?

Diagnosis of atrophic vulvovaginitis is usually based on a woman’s symptoms and a physical examination^[3][9]. Your doctor will ask about your medical history, including whether you have gone through menopause or are experiencing menopausal symptoms such as irregular periods, hot flashes, or night sweats^[6]. The doctor will also ask about any medications you take, as some medicines can lower estrogen levels^[6].

A pelvic examination is usually performed to confirm the diagnosis. During this exam, the doctor looks at your vulva and vagina to check for signs of thinning, dryness, redness, and changes in tissue appearance^[1][3]. The examination may show that the vaginal walls are thin and pale, with visible small blood vessels underneath^[3].

Several tests may be done to confirm the diagnosis and rule out other conditions^[1][3]:

• Vaginal pH test: A sample of vaginal fluid is tested to measure its acidity. A pH of 4.6 or higher supports the diagnosis of atrophic vulvovaginitis^[3][7].
• Vaginal swab or wet mount examination: This test looks at cells from the vaginal wall under a microscope and can help identify any infection^[3].
• Urine test: If you have urinary symptoms, your urine may be collected and tested to check for infection^[1].
• Biopsy: In some cases, a small sample of tissue may be taken to make sure there is no other skin disease or cancer causing your symptoms^[3].

If you have bleeding after intercourse and are postmenopausal, your doctor may want to check for cancer of the uterine lining by doing an endometrial biopsy^[6]. A Pap test may also be done to check for problems with the cervix^[6].

Treatment Options

Effective treatments are available for atrophic vulvovaginitis, and most women can find significant relief from their symptoms^[1]. Treatment options range from over-the-counter products to prescription hormone therapy. The choice of treatment depends on the severity of symptoms and individual health factors^[11].

Over-the-Counter Options

For mild symptoms, your doctor may first recommend non-prescription treatments^[11]:

• Vaginal moisturizers: These products help restore moisture to the vaginal area and are typically applied every few days. They can provide longer-lasting relief than lubricants^[1][11].
• Water-based lubricants: These are applied just before sexual activity to reduce discomfort during intercourse. Products without glycerin or warming properties are often better for women who are sensitive to irritation^[11]. Natural oils like coconut oil can also be used^[8].

It is important to avoid petroleum jelly or other petroleum-based products if you use latex condoms, as petroleum can break down the condoms^[11].

Hormone Treatments

If over-the-counter options do not provide enough relief, hormone therapy is usually very effective^[3][6]. Topical estrogen (estrogen applied directly to the vagina) is the most common prescription treatment^[3]. It comes in several forms:

• Vaginal cream: Estrogen cream is inserted into the vagina with an applicator or applied with a fingertip, usually once daily for 1-2 weeks, then once or twice weekly^[3].
• Vaginal tablets or pessaries: Small tablets containing estrogen are inserted into the vagina^[3].
• Vaginal ring: A soft, flexible ring containing estrogen is placed in the vagina and releases hormone slowly over time^[10].

Topical estrogen has the advantage of being effective at lower doses than oral estrogen, and less hormone reaches the bloodstream^[11]. This treatment leads to several improvements: the vaginal wall cells become more normal, blood flow to the vagina increases, the vaginal pH decreases back to a healthier level, healthy lactobacilli bacteria return, and the vagina becomes thicker and more elastic^[3].

Some women may benefit from systemic hormone therapy (taking estrogen by mouth or through a skin patch), but even women taking systemic estrogen may still need topical vaginal estrogen if they continue to have vaginal symptoms^[7].

Other Treatment Options

For women who cannot or prefer not to use estrogen, other options may be available. Some research suggests that combining probiotics with other treatments may help improve symptoms^[8]. Vitamin D and vitamin E vaginal creams or suppositories have shown promise in some studies^[8].

Prevention and Self-Care

Several self-care measures can help prevent or reduce symptoms of atrophic vulvovaginitis^[3][6][8]:

• Stay sexually active: Regular sexual activity (with or without a partner) helps improve blood circulation to the vagina, which helps maintain vaginal tissue health and elasticity^[2][6].
• Quit smoking: Smoking decreases estrogen levels and increases the risk of vaginal atrophy. Giving up smoking can help prevent symptoms^[8][17].
• Use gentle hygiene: Wash the vulva gently with warm water alone or use a non-soap cleanser, no more than once or twice daily. Avoid douching^[3][10].
• Avoid irritants: Do not use perfumed soaps, powders, deodorants, or other scented products on the genital area, as these can cause irritation^[3].
• Stay hydrated: Drinking plenty of fluids helps maintain moisture levels in the body^[8].
• Exercise regularly: Frequent physical activity helps with hormone balance^[8].
• Apply moisturizing cream: If the vulva feels dry or itchy, apply an emollient cream suitable for sensitive skin or petroleum jelly^[3].

If you develop symptoms of atrophic vulvovaginitis, do not suffer in silence. Talk to your doctor. Simple, effective treatments are available, and you do not have to live with discomfort^[1]. Make an appointment if you experience unexplained vaginal bleeding or spotting, unusual discharge, burning, soreness, or painful intercourse^[1].