Atrophic Vaginitis

Background

• Atrophic vaginitis refers to anatomic and physiologic changes in the vaginal tract commonly due to natural or induced menopause or other conditions associated with hypoestrogenic states.
• Symptoms due to atrophic vaginal changes are reported in 20%-45% of postmenopausal women. Symptoms may include vaginal dryness, irritation, pruritus, burning, dysuria, dyspareunia, vaginal discharge, or bleeding.

Evaluation

• Diagnosis is typically made by patient-reported symptoms and evidence of vaginal atrophy on pelvic exam (thin, pale, and dry vulvar and vaginal tissues). Signs may be out of proportion to symptoms.
• A vaginal pH test and/or vaginal maturation index assessment may help confirm vaginal atrophy but is not required for the diagnosis in clinical practice.

Management

• The goal of treatment is to eliminate symptoms.
• Nonhormonal vaginal lubricants and moisturizers are recommended as first-line treatment for women with symptomatic vaginal atrophy. Regular use may provide long-term relief of vaginal dryness, itching, irritation, and dyspareunia, particularly in women with mild-to-moderate symptoms, and should be considered as initial treatment in women with potential contraindications to estrogen therapy (Strong recommendation).
• Estrogen therapy (local or systemic) is recommended for symptomatic women with moderate-to-severe atrophy or mild atrophy with symptoms not effectively controlled by lubricants and moisturizers (Strong recommendation).
  • Low-dose vaginal estrogen is preferred over systemic estrogen for women with vaginal atrophy as the only menopausal symptom, and may be considered in short courses for women with a history of hormone-dependent cancers (Strong recommendation). Low-dose vaginal estrogen is associated with fewer adverse effects than systemic estrogen.
  • Consider systemic estrogen therapy (oral or transdermal) for women with vaginal atrophy and concurrent vasomotor symptoms (Strong recommendation).
  • Symptoms of vaginal atrophy that are unresponsive to estrogen therapy may indicate an alternate underlying cause.
• Additional treatments:
  • Consider ospemifene (Osphena), a selective estrogen receptor modulator (SERM), for the treatment of moderate-to-severe dyspareunia and symptoms of vulvovaginal atrophy in postmenopausal women (Strong recommendation). Ospemifene is not recommended in women with breast cancer or at high risk for breast cancer due to insufficient evidence for use in this population.
  • Consider bazedoxifene/conjugated estrogen tablets for improving symptoms of moderate-to-severe vulvovaginal atrophy in postmenopausal women.
• Regular sexual activity should be encouraged if it is not painful or uncomfortable.
• Sex therapy may help address nonphysical and relational aspects of pain, discomfort, and vaginal dryness associated with sexual intercourse.