Postmenopausal atrophic vaginitis, or vaginal atrophy, is the thinning of the walls of the vagina caused by decreased estrogen levels. This most commonly occurs after menopause.
Menopause is the time in a woman’s life, usually between ages 45 and 55, when her ovaries no longer release eggs. She also stops having menstrual periods. A woman is postmenopausal when she has not had a period for 12 months or more.
Women with vaginal atrophy have a greater chance of chronic vaginal infections and urinary function problems. It can also make sexual intercourse painful.
According to the American Association of Family Physicians, up to 40 percent of postmenopausal women have atrophic vaginitis.
While vaginal atrophy is common, only 20 or 25 percent of women seek medical attention from their doctor.
In some women, symptoms occur during perimenopause, or the years leading up to menopause. In other women, symptoms may not appear until years later, if ever.
Symptoms can include:
- thinning of the vaginal walls
- shortening and tightening of the vaginal canal
- lack of vaginal moisture (vaginal dryness)
- vaginal burning (inflammation)
- spotting of blood after intercourse
- discomfort or pain during intercourse
- pain or burning with urination
- more frequent urinary tract infections
- urinary incontinence (involuntary leakage)
The cause of atrophic vaginitis is a decline in estrogen. Without estrogen, vaginal tissue thins and dries out. It becomes less elastic, more fragile, and more easily injured.
A decline in estrogen can occur at other times besides menopause, including:
- during breast-feeding
- after removal of ovaries (surgical menopause)
- after chemotherapy for treatment of cancer
- after pelvic radiation therapy for treatment of cancer
- after hormonal therapy for treatment of breast cancer
Regular sexual activity helps keep vaginal tissues healthy. A healthy sex life also benefits the circulatory system and improves heart health.
Some women are more likely than others to get atrophic vaginitis. Women who have never given birth vaginally are more prone to vaginal atrophy than women who delivered their babies vaginally.
Smoking impairs blood circulation, depriving the vagina and other tissues of oxygen. Tissue thinning occurs where blood flow is decreased or restricted. Smokers are also less responsive to estrogen therapy in pill form.
Atrophic vaginitis increases a woman’s risk of contracting vaginal infections. Atrophy causes changes in the acidic environment of the vagina, making it easier for bacteria, yeast, and other organisms to thrive.
It also increases the risk of urinary system atrophy (genitourinary atrophy). Symptoms associated with atrophy-related urinary tract problems include more frequent or more urgent urination or a burning sensation during urination.
Some women may also have incontinence and get more urinary tract infections.
Testing and Diagnosis
See your doctor right away if sexual intercourse is painful, even with lubrication. You should also see your doctor if you experience unusual vaginal bleeding, discharge, burning, or soreness.
Some women are embarrassed to talk to their doctor about this intimate problem. If you are experiencing these symptoms, it is important to seek the advice of a doctor to help avoid the potential complications mentioned above.
Your doctor will ask you questions about your health history. They’ll want to know how long ago you stopped having periods and whether you have ever had cancer. The doctor may ask what, if any, commercial or over-the-counter products you use. Some perfumes, soaps, bath products, deodorants, lubricants, and spermicides can aggravate the sensitive sexual organs.
Your doctor may refer you to a gynecologist for tests and a physical examination. During a pelvic exam, they will palpate or feel your pelvic organs. The doctor will also examine your external genitalia for physical signs of atrophy, such as:
- pale, smooth, shiny vaginal lining
- loss of elasticity
- sparse pubic hair
- smooth, thin external genitalia
- stretching of uterine support tissue
- pelvic organ prolapse (bulges in the walls of the vagina)
The doctor might order the following tests:
- pelvic examination
- vaginal smear test
- vaginal acidity test
- blood test
- urine test
The smear test is a microscopic examination of tissue that has been scraped from the vaginal walls. It looks for certain types of cells and bacteria that are more prevalent with vaginal atrophy.
To test acidity, a paper indicator strip is inserted into the vagina. Your doctor can also collect vaginal secretions for this test.
You may also be asked to provide samples of blood and urine for laboratory testing and analysis. These tests check several factors, including your estrogen levels.
With treatment, it’s possible to improve your vaginal health and your quality of life. Treatment can focus on symptoms or the underlying cause.
Over-the-counter moisturizers or water-based lubricants can help treat dryness.
If symptoms are severe, your doctor may recommend estrogen replacement therapy. Estrogen improves vaginal elasticity and natural moisture. It usually works in just a few weeks. Estrogen can be taken either topically or orally.
Taking estrogen through the skin limits how much estrogen gets into the bloodstream. Topical estrogens also do not treat any systemic symptoms of menopause, like hot flashes, etc. These types of estrogen treatments have not been shown to increase the risk of endometrial cancer. However, call your doctor right away if you’re using topical estrogen and experience unusual vaginal bleeding.
Topical estrogen is available in several forms to fit your preferences:
- A vaginal estrogen ring, such as Estring. Estring is a flexible, soft ring inserted into the upper part of the vagina by you or your doctor. It releases a constant dose of estrogen and only has to be replaced every three months. Estrogen rings are higher dose estrogen preparations and may increase a woman’s risk for endometrial cancer. You should speak with your physician about your risk and possible need for progestin as well.
- A vaginal estrogen cream, such as Premarin or Estrace. These types of medications are inserted into the vagina with an applicator at bedtime. Your doctor may prescribe the cream daily for a couple of weeks, then step down to two or three times per week.
- A vaginal estrogen tablet, such as Vagifem, is inserted into the vagina using a disposable applicator. It’s usually prescribed one dose per day to start, stepping down to one or two times per week.
During menopause, oral estrogen is often used to treat hot flashes and vaginal dryness. But prolonged use heightens the risk of certain cancers. If you’ve ever had cancer, oral estrogen is not usually prescribed.
If your health history doesn't include cancer, progesterone may be prescribed in addition to estrogen in pill or patch form. Your doctor will work with you to decide which option is best for you.
Women taking progesterone and estrogen may have some bleeding after menopause. While the cancer risk for women taking both progesterone and estrogen is minimal, you should still see your doctor to have any episodes of postmenopausal bleeding evaluated. This can be an early sign of endometrial cancer.
Besides medication, there are certain lifestyle changes you can make as well.
Wearing cotton underwear and loose-fitting clothing can improve symptoms. Loose cotton clothing improves air circulation around the genitals, making them a less ideal environment for bacteria to grow.
A woman with atrophic vaginitis can experience pain during sexual intercourse. However, staying sexually active enhances blood circulation in the vagina and stimulates natural moisture. Sexual activity has no effect on estrogen levels. But by improving blood circulation, it keeps your sexual organs healthier for longer. Allowing time to become sexually aroused can make sexual intercourse more comfortable.
Vitamin E oil can also be used as a lubricant. There’s also some evidence that vitamin D increases moisture in the vagina. Vitamin D also helps the body absorb calcium. This helps to slow or prevent postmenopausal bone loss, especially when combined with regular exercise.