Atrophic vaginitis

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Atrophic vaginitis
ICD-10	N95.2
ICD-9	627.3
DiseasesDB	32516
MedlinePlus	000892

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

Synonyms and keywords: Atrophic vulvovaginitis; vaginal atrophy; urogenital atrophy; genitourinary syndrome of menopause

Pathophysiology

Pathogenesis

The pathogenesis of atrophic vaginitis is related to decreased estrogen levels. Estrogen is a vasoactive hormone, which increases blood flow and maintain vaginal lubrication through fluid transudation from blood vessels. The following are the manifestations of decreased estrogen levels:

• A hypoestrogenic state, such as that seen in menopause, causes the vaginal epithelium to lose its rugae, as well as become thin and pale or erythematous with fine petechial hemorrhages.
• Decreased glycogen content within the epithelium due to decreased thickness leads to less glycogen content available for the lactobacilli to utilize and turn it into lactic acid. As a result, the vaginal pH rises with a resultant overgrowth of other bacteria, such as group B streptococci, Staphylococci and diptheroids. As a result, vaginal infections, UTI and inflammation become more common in the setting of atrophic vaginitis.

Gross Pathology

Gross pathology findings in atrophic vaginitis include:

• Vaginal dryness
• Loss of vaginal rugae
• Changes in vaginal mucosa: pallor and friability or redness and petechiae of the mucosa

Causes

Atrophic vaginitis is caused by any condition that may lead to decreased circulating estrogen levels. A hypoestrogenic state may be due to ovarian failure or other causes:

• Ovarian failure: this category includes menopause, premature ovarian failure, bilateral oophorectomy, chemotherapy and radiation
• Other causes: elevated prolactin levels, due to lactation or pituitary adenoma, or medications that have an anti-estrogenic effect

Epidemiology and Demographics

• Atrophic vaginitis is often an underdiagnosed condition, because many women are embarrassed to discuss their symptoms. Some others think of the symptoms associated with atrophic vaginitis as a process of natural aging.
• Based on self-reported symptoms of vaginal dryness, the prevalence of atrophic vaginitis ranged from 4% to 47%, depending on the stage of menopause (early or late menopause).

Risk Factors

The risk factors associated with vaginal atrophy are related to decreased estrogen levels, which can be due to menopause (most common cause) or other causes that may lead to hypoestrogenism or vaginal atrophy. These include:

• Menopause (most common cause)
• Bilateral oophorectomy
• Premature ovarian failure
• Decreased ovarian function, due to chemotherapy or radiation
• Medications with an anti-estrogenic side effect:
  • Tamoxifen
  • Danazol
  • Medroxyprogesterone acetate
  • GnRH agonsists: leuprolide, nafarelin, goserelin
  • GnRH antagonists: ganirelix
• Elevated prolactin levels during lactation
• Sexual abstinence
• Vaginal nulliparity
• Smoking
• Alcohol abuse
• Lack of exercise

Screening

There are no screening recommendations for atrophic vaginitis.

Differentiating atrophic vaginitis from other diseases

Atrophic vaginitis must be differentiated from other disease processes that may present with similar symptoms. These can be divided into 4 categories:

• Vaginal infections: Candida vulvovaginitis, bacterial vaginosis and trichomoniasis
• Vulvovaginal dermatoses: lichen sclerosus, lichen planus and lichen simplex chronicus
• Cancer and precancerous lesions: vulvar intraepithelial neoplasia, vulvar cancer and extramammary Paget disease
• Others: foreign body, sexual trauma and contact irritants

Natural History, Complications and Prognosis

Complications

Complications of atrophic vaginitis include:

• Stress urinary incontinence
• Urge incontinence
• Pelvic organ prolapse
• Recurrent urinary tract infections
• Sexual dysfunction

Diagnosis

History and Symptoms

Symptoms of atrophic vaginitis can be divided into three categories:

• External genital symptoms:
  • Vaginal dryness
  • Vaginal irritation
  • Vaginal itching
  • Vaginal discharge

• Sexual symptoms:
  • Painful sexual intercourse (dyspareunia)
  • Postcoital bleeding
  • Loss of bleeding
  • Loss of arousal
  • Pelvic pain

• Urological symptoms:
  • Burning on urination (dysuria)
  • Urinary frequency
  • Urinary urgency
  • Nocturia
  • Urinary incontinence
  • Recurrent urinary tract infections (UTI)

Physical Examination

Physical examination in women with atrophic vaginitis includes a general inspection of the external genitalia, as well as a speculum examination of the internal genitalia.

• Physical examination in women with atrophic vaginitis begins with inspection of the external genitalia. Findings include decreased elasticity of the skin, sparsity of pubic hair, dryness of the labia and/or fusion of the labia minora.
• Gynecologic examination is carried using a small speculum to avoid damage to the atrophic vaginal or vulvar tissue. Vaginal epithelium may be atrophic and appear pale, smooth and shiny, or it may be inflamed, with patchy erythema, petechiae and increased friability.
• Other findings may include: pelvic organ prolapse, such as cystocele and/or rectocele, urethral polyps or eversion of the urethral mucosa.

Ultrasound

An ultrasound of the uterus may demonstrate thinning of the endometrium lining to 4-5mm.

Treatment

Medical Therapy

The mainstay of treatment of atrophic vaginitis is medical therapy. It can be categorized into two groups:

• Nonhormonal therapy: this includes vaginal moisturizers and lubricants
• Hormonal therapy: this includes vaginally administered local estrogens, which can be in the form of cream, ring or tablet

References

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