Atrophic vaginitis
Other names	Vulvovaginal atrophy,[1] vaginal atrophy,[1] genitourinary syndrome of menopause,[1] estrogen deficient vaginitis[2]
Normal vaginal mucosa (left) versus vaginal atrophy (right)
Specialty	Gynecology
Symptoms	Pain with sex, vaginal itchiness or dryness, an urge to urinate[1]
Complications	Urinary tract infections[1]
Duration	Long term[1]
Causes	Lack of estrogen[1]
Risk factors	Menopause, breastfeeding, certain medications[1]
Diagnostic method	Based on symptoms[1]
Differential diagnosis	Infectious vaginitis, vulvar cancer, contact dermatitis[2]
Treatment	Vaginal estrogen[1]
Frequency	Half of women (after menopause)[1]

Atrophic vaginitis is inflammation of the vagina as a result of tissue thinning due to low estrogen levels.^[2] Symptoms may include pain with sex, vaginal itchiness or dryness, and an urge to urinate or burning with urination.^[1][3] It generally does not resolve without ongoing treatment.^[1] Complications may include urinary tract infections.^[1] Atrophic vaginitis as well as vulvovaginal atrophy, bladder and urethral dysfunctions are a group of conditions that constitute Genitourinary Syndrome of Menopause (GSM). ^[4] Diagnosis is typically based on symptoms.^[1]

The lack of estrogen typically occurs following menopause.^[1] Other causes may include breastfeeding or using specific medications.^[1] Risk factors include smoking.^[2]

Treatment for atrophic vaginitis may involve the use of topical estrogen or other estrogen replacement. To treat the symptoms, patients may use lubricants, but it may not help long term as it does not affect the tissues.^[5]

Atrophic vaginitis may be caused by tissue thinning, loss of elasticity, and loss of vaginal fluids from low estrogen levels. ^[6] Normal menopause and treatments such as chemotherapy or medications may result in loss of estrogen.

Those with or had a history of breast cancer may be at a higher risk of developing atrophic vaginitis due to chemotherapy and other endocrine treatments. ^[4] Estrogen is crucial for women's sexual and urinary health.^[7] It supports the tissues in the lower vagina and urinary tracts to keep them thick, elastic, and mosit and ensuring good blood flow.^[7][8] Estrogen helps maintain a thick, glycogen-rich vaginal lining, which healthy bacteria use to produce lactic acid to keep the vaginal environment acidic, reducing infection risks.^[7] In premenopausal women, the main form of estrogen is called estradiol and fluctuates between 40 and 200 pg/mL, rising to 600 pg/mL during ovulation.^[7] Postmenopause, estrogen levels drop significantly tp 5-18 pg/mL, leading to gradual changes in the urogenital area.^[7] All tissue types such as connective, epithelial, muscular, blood vessels, and nerves are affected and become thinner and less effective, which increases risk of infections, inflammation, injuries, and sores.^[7] Blood flow and sensation can decrease, causing pain during sex and the pH level can rise due to decreased lactic acid production, which can allow harmful bacteria and fungi to grow and cause infections.^[7]

After menopause the vaginal epithelium changes and becomes a few layers thick.^[9] Many of the signs and symptoms that accompany menopause occur in atrophic vaginitis.^[10] Genitourinary symptoms include

• dryness^[3][11]
• pain^[3][11]
• itching^[3][1]
• burning^[3][11]
• soreness
• pressure
• white discharge
• malodorous discharge due to infection
• painful sexual intercourse
• bleeding after intercourse^[12]
• painful urination^[3]
• blood in the urine
• increased urinary frequency^[3][11]
• incontinence
• increased susceptibility to infections^[3]
• decreased vaginal lubrication^[11]
• urinary tract infections^[1][11]
• painful urination^[11]
• difficulty sitting^[1]
• difficulty wiping^[1]
• thin, clear discharge^[13]

It can be challenging to diagnose atrophic vaginitis given that the symptoms are mild and nonspecific for many postmenopausal women.^[14] Since women can have signs and symptoms that could be attributed to other causes, diagnosis is based upon the symptoms that cannot be better accounted for by another diagnosis.^[11]

Lab tests usually do not provide information that will aid in diagnosing. A visual exam is useful. The observations of the following may indicate lower estrogen levels: little pubic hair, loss of the labial fat pad, thinning and resorption of the labia minora, and the narrowing of the vaginal opening. An internal exam will reveal the presence of low vaginal muscle tone, the lining of the vagina appears smooth, shiny, pale with loss of folds. The cervical fornices may have disappeared and the cervix can appear flush with the top of the vagina. Inflammation is apparent when the vaginal lining bleeds easily and appears swollen.^[1] The vaginal pH will be measured at 4.5 and higher.^[15] Papillary and reticular, as well as skin and dermal tissue atrophy are observed via histological examinations. Observed reduced vascularization, atrophy of epithelial tissue leading to reduced thickness, and paleness are all apparent in post-menopausal women during histological examinations.^[16]

Symptoms of genitourinary syndrome of menopause (GSM) will unlikely be resolved without treatment.^[1] Women may have many or a few symptoms so treatment is provided that best suits each woman. If other health problems are also present, these can be taken into account when determining the best course of treatment. For those who have symptoms related to sexual activities, a lubricant may be sufficient.^[1][17] If both urinary and genital symptoms exist, local, low-dose estrogen therapy can be effective. Those women who are survivors of hormone-sensitive cancer may need to be treated more cautiously.^[1] Some women can have symptoms that are widespread and may be at risk for osteoporosis. Estrogen and adjuvants may be best.^[17]

Topical treatment with estrogen is effective when the symptoms are severe and relieves the disruption in pH to restore the microbiome of the vagina. When symptoms include those related to the urinary system, systematic treatment can be used. Recommendations for the use of the lowest effective dose for the shortest duration help to prevent adverse endometrial effects.^[17] Treatment is generally with estrogen cream applied to the vagina.^[1] It is recommended that soaps and other irritants are avoided.^[2]

Some treatments have been developed more recently. These include selective estrogen receptor modulators, vaginal dehydroepiandrosterone, and laser therapy. Other treatments are available without a prescription such as vaginal lubricants and moisturizers. Vaginal dilators may be helpful. Since GSM may also cause urinary problems related to pelvic floor dysfunction, a woman may benefit from pelvic floor strengthening exercises. Women and their partners have reported that estrogen therapy resulted in less painful sex, more satisfaction with sex, and an improvement in their sex life.^[1] If women cannot tolerate or use estrogen therapy, topical hyaluronic acid can be used as another option which has been shown to be safe and effective.^[18] Vitamin E vaginal suppositories were also found to be helpful in relieving symptoms of GSM, but further studies need to be done to evaluate how safe and effective this treatment is for this condition.^[19]

Atrophic vaginitis develops in 10-50% of postmenopausal women. Of those who are postmenopausal and have developed atrophic vaginitis, 50-70% develop symptoms.^[1][14] Around 30% of women with atrophic vaginitis discuss their symptoms with their primary healthcare provider. It is likely to be under diagnosed and under treated due to lack of awareness of those who are affected by atrophic vaginitis and of healthcare providers.^[20] Symptoms of genitourinary syndrome of menopause (GSM) are seen in 65% women one year post-menopause versus 87% six years post-menopause.^[14]

Vulvovaginal atrophy and atrophic vaginitis have been the preferred terms for this condition and cluster of symptoms until recently. These terms are now regarded as inaccurate in describing changes to the entire genitourinary system occurring after menopause. The term atrophic vaginitis suggests that the vagina is inflamed or infected. Though this may be true, inflammation and infection are not the major components of postmenopausal changes to the vagina. The former terms do not describe the negative effects on the lower urinary tract which can be the most troubling symptoms of menopause for women.^[3] Genitourinary syndrome of menopause (GSM) was determined to be more accurate than vulvovaginal atrophy by two professional societies.^[1][11][a] The term atrophic vaginitis does not reflect the related changes of the labia, clitoris, vestibule, urethra and bladder.^[11] Overall, the current preferred term is Genitourinary syndrome of Menopause (GSM). It is an umbrella term for vulvovaginal atrophy, atrophic vaginitis, urogenital atrophy and vaginal atrophy. ^[21]

In 2018, the FDA issued a warning that lasers and other high energy devices were not approved for "rejuvenating" the vagina, and it has received many reports of injuries.^[22] Such devices are scams and have been shown to only cause necrosis and extreme pain to lead to suicidal ideation.^[23]

A 12-week randomized controlled clinical trial conducted in Ardabil, Iran, in 2018 evaluated the effectiveness of fenugreek extract on atrophic vaginitis in 60 postmenopausal women.^[24] Research participants were dividied into an intervention group, which received fenugreek vaginal cream, and a control group, which received conjugated estrogen vaginal cream.^[24] The study measured clinical signs and the Vaginal Maturation Index (VMI).^[24] The results indicated that while fenugreek extract showed some efficacy in treating atrophic vaginitis, it was significantly less effective that ultra-low-dose estrogen as evidenced by higher VMI scores and greater improvement in clinical signs in the control group.^[24]