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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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
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
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