From the Guidelines
In atrophic vaginitis, the vaginal pH increases above the normal range of 3.8-4.5, typically rising to 5.0-7.0, as a result of estrogen deficiency leading to thinning of the vaginal epithelium and reduced glycogen content in vaginal cells. This elevation occurs because the decreased glycogen availability leads to decreased colonization by Lactobacillus bacteria, which normally produce lactic acid that maintains the acidic vaginal environment 1. The resulting higher pH creates a more alkaline environment that favors the growth of pathogenic bacteria, contributing to symptoms such as vaginal dryness, burning, itching, and discomfort.
Key Factors Contributing to pH Change
- Estrogen deficiency
- Thinning of the vaginal epithelium
- Reduced glycogen content in vaginal cells
- Decreased colonization by Lactobacillus bacteria
Diagnostic and Therapeutic Implications
The pH change is a key diagnostic feature of atrophic vaginitis and helps distinguish it from other vaginal conditions. Treatment typically involves local or systemic estrogen therapy to restore the vaginal epithelium, increase glycogen production, and subsequently normalize the vaginal pH by promoting the return of Lactobacillus colonization 1. According to the most recent guidelines, vaginal estrogen is the most effective treatment for vaginal dryness leading to sexual dysfunction and has been shown to be effective in treating itching, discomfort, and painful intercourse in postmenopausal individuals 1.
Recent Guidelines and Recommendations
Recent studies, such as the NCCN guidelines, suggest that vaginal estrogen can be safely used in survivors of hormone receptor-positive breast cancer receiving aromatase inhibitor therapy, with no evidence of increased risk of breast cancer-specific mortality 1. However, the safety of vaginal hormones has not been firmly established in survivors of estrogen-dependent cancers, and their use should be approached with caution. The use of vaginal estrogen, such as an estradiol-releasing vaginal ring, is recommended as a first-line treatment for atrophic vaginitis, given its efficacy in restoring the vaginal epithelium and normalizing the vaginal pH.
From the Research
Vaginal pH in Atrophic Vaginitis
- The vaginal pH in atrophic vaginitis is increased due to estrogen deficiency 2, 3.
- This increase in vaginal pH predisposes the vagina and urinary tract to infection and mechanical weakness 2.
- The increased vaginal pH is a result of the thinned endometrium and decreased levels of estrogen 2.
- The testing of the vaginal pH can serve as a surrogate for evaluating urethral pH and as a monitor of compliance with treatment 3.
- Locally applied vaginal conjugated estrogen cream can normalize the pH in the vagina and urethra 3.
Symptoms and Treatment
- Atrophic vaginitis is associated with symptoms such as vaginal dryness, dyspareunia, and recurrent urinary tract infections 4, 5.
- Treatment usually depends on estrogen replacement, which can be provided systemically or locally 2.
- Vaginal moisturizers and lubricants, and participation in coitus may also be beneficial in the treatment of women with atrophic vaginitis 2, 4.
- Topical estrogen replacement therapies can reverse mucosal changes and are effective treatments for the symptoms of atrophic vaginitis 4.