Atrophic Vaginitis (Genitourinary Syndrome of Menopause)
Hypoestrogenic atrophy of vulvovaginal and lower urinary tract tissues.
Also known as: atrophic vaginitis, vulvovaginal atrophy, GSM, genitourinary syndrome of menopause
Overview
A constellation of vulvar, vaginal, and lower urinary tract signs and symptoms due to decreased estrogen, now termed Genitourinary Syndrome of Menopause (GSM) by NAMS/ISSWSH (2014). Includes dryness, burning, dyspareunia, urinary urgency, dysuria, and recurrent UTIs.
Epidemiology
Affects 27-84% of postmenopausal women; underdiagnosed because patients and clinicians often do not raise the topic. Also occurs with surgical menopause, postpartum lactation, antiestrogen therapy (aromatase inhibitors, GnRH agonists, tamoxifen variably).
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Risk factors
- Menopause (natural, surgical, premature ovarian insufficiency)
- Antiestrogen therapy: aromatase inhibitors, GnRH agonists, tamoxifen, chemotherapy
- Postpartum lactation
- Smoking (lower estrogen levels, earlier menopause)
- Lack of vaginal intercourse (loss of vascular response)
Pathophysiology
Estrogen deficiency leads to thinning of the vaginal epithelium with loss of glycogen-rich superficial cells, increase in vaginal pH (>5), decrease in lactobacilli, reduced lubrication, decreased elasticity, and shortening of the vagina. Similar atrophic changes affect the urethra and trigone, contributing to lower urinary tract symptoms.
Clinical presentation
Symptoms
- Vulvovaginal: dryness, burning, irritation, dyspareunia, postcoital bleeding, loss of lubrication
- Urinary: urgency, dysuria, recurrent UTI, urinary incontinence
Signs / physical exam
- Pale, thin, friable vaginal mucosa with loss of rugae
- Decreased elasticity, vaginal shortening, narrow introitus
- Petechiae or fissures with manipulation; cervical retraction
- Vulvar findings: thinning of labia minora, loss of pubic hair
Differential diagnosis
- Vulvovaginal candidiasis — Thick white discharge, pruritus; wet mount with budding yeast/pseudohyphae; vaginal pH normal (<4.5)
- Bacterial vaginosis / trichomoniasis — Malodorous discharge, positive whiff, clue cells (BV) or motile trichomonads
- Lichen sclerosus or lichen planus — Architectural changes (loss of labia minora, agglutination), white plaques, severe pruritus — biopsy
- Contact or allergic dermatitis — Recent product exposure; erythema, fissures
- Vulvar intraepithelial neoplasia or carcinoma — Persistent plaque, ulcer, or pigmented lesion — biopsy
- Recurrent UTI (alternative cause) — Positive urine culture; address pathogen and contributing factors
Diagnostic workup
Diagnostic criteria
Clinical — typical symptoms and exam findings in a hypoestrogenic patient, with exclusion of infection and dermatoses. Biopsy any suspicious lesion.
Labs
- Wet mount: increased parabasal cells, paucity of lactobacilli, vaginal pH >5
- Exclude infection: NAAT for GC/CT, wet mount or NAAT for trichomonas, KOH for yeast
- Urinalysis if urinary symptoms
Imaging
- Not routinely needed
Diagnostic algorithm
| Therapy | Formulation | Notes |
|---|---|---|
| Moisturizer | Polycarbophil, hyaluronic acid | Non-hormonal, 2-3x weekly |
| Lubricant | Water- or silicone-based | With intercourse |
| Vaginal estradiol cream | Cream 0.01% | Daily x 2 wk then 1-3x weekly |
| Estradiol vaginal tablet | 10 mcg insert | Daily x 2 wk then 2x weekly |
| Estradiol vaginal ring | Estring 7.5 mcg/day | Replace every 90 days |
| Prasterone (DHEA) | 6.5 mg suppository | Nightly |
| Ospemifene | 60 mg PO daily | SERM; for dyspareunia |
Treatment
First-line
- Non-hormonal: long-acting vaginal moisturizers (e.g., polycarbophil/Replens) 2-3x weekly, water- or silicone-based lubricants with intercourse
- Continued sexual activity (with adequate lubrication) helps preserve vaginal tissue health
Hormonal therapy (when non-hormonal insufficient)
- Low-dose vaginal estrogen — first-line pharmacologic therapy: estradiol cream (Estrace) or conjugated equine estrogen cream, estradiol vaginal tablet (Vagifem/Yuvafem) 10 mcg, or estradiol vaginal ring (Estring) 7.5 mcg/day — minimal systemic absorption; progestin not required for endometrial protection at standard doses
- Initial dosing typically daily x 2 weeks, then 1-3x weekly maintenance
- Symptoms generally improve in 4-12 weeks; safe long-term per NAMS
- Vaginal DHEA (prasterone, Intrarosa) 6.5 mg suppository nightly — alternative
- Oral ospemifene (SERM) 60 mg daily — for moderate-severe dyspareunia; not appropriate in women with VTE risk or estrogen-sensitive cancer
Patients with history of breast cancer
- Non-hormonal therapies first-line (moisturizers, lubricants)
- If insufficient, vaginal estrogen may be considered with oncology input; current evidence does not show increased recurrence with low-dose vaginal estrogen in most settings
- Aromatase inhibitors may have additive vaginal effects — patients on these benefit most from vaginal moisturizers, with vaginal DHEA or low-dose estrogen considered on a case-by-case basis
Second-line / adjunct
- Systemic menopausal hormone therapy if vasomotor symptoms also present — though local therapy is preferred for isolated GSM
- Pelvic floor physical therapy for associated dyspareunia or vaginismus
- Energy-based therapies (CO2 laser, radiofrequency) — FDA has cautioned that efficacy and safety are not established; not first-line
Complications
- Sexual dysfunction, reduced quality of life
- Recurrent UTI
- Bleeding from friable atrophic tissue (must rule out endometrial pathology in postmenopausal bleeding)
- Vaginal stenosis
PANCE pearls
- Postmenopausal bleeding is endometrial cancer until proven otherwise — even when atrophic vaginitis is suspected, evaluation with endometrial sampling and/or transvaginal ultrasound is required.
- Low-dose vaginal estrogen has minimal systemic absorption and does not require concurrent progestin; it is safe for long-term use per NAMS.
- Vaginal pH >5 with paucity of lactobacilli on wet mount supports the diagnosis.
- Symptoms of GSM, unlike vasomotor symptoms, tend to worsen rather than improve with time without treatment.
- Vaginal estrogen is acceptable in many breast cancer survivors, but should be a shared decision with their oncologist.
References
- NAMS 2020 — NAMS 2020 Genitourinary Syndrome of Menopause Position Statement (Menopause 2020)
- ACOG PB 141 — ACOG Practice Bulletin 141: Management of Menopausal Symptoms
- ISSWSH/NAMS — Portman & Gass, Menopause 2014 — terminology consensus (GSM)
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