What are the symptoms and treatment options for atrophic vaginitis?

Symptoms of Atrophic Vaginitis

Atrophic vaginitis is characterized by vaginal dryness, itching, burning sensation, discomfort or pain during sexual intercourse (dyspareunia), and vaginal discharge, affecting approximately one-third of postmenopausal women and significantly impacting quality of life. 1, 2

Common Symptoms

• Vaginal dryness is typically the earliest symptom, followed by other vaginal and urinary symptoms 1, 3
• Itching and burning sensation in the vulvovaginal area 1, 2
• Discomfort or pain during sexual intercourse (dyspareunia) 1, 2
• Vaginal discharge, often white in appearance 1
• Urinary tract infections and urinary urgency 1
• Vaginal pH is typically elevated (>4.5) 1

Progression and Impact

• Unlike vasomotor symptoms which tend to resolve over time, atrophic vaginitis symptoms may persist indefinitely and often worsen with time if left untreated 1, 2
• The condition affects approximately 50% of postmenopausal women 1, 4
• Symptoms can significantly impact sexual health and overall quality of life 1, 5
• The thinned endometrium and increased vaginal pH level induced by estrogen deficiency predispose the vagina and urinary tract to infection and mechanical weakness 3

Risk Factors and Causes

• Low circulating estrogen levels are the primary cause of atrophic vaginitis 1
• The condition is particularly common in women who undergo bilateral oophorectomy 1
• Aromatase inhibitors can inhibit peripheral conversion of androgens to estrogens by >95%, leading to more severe symptoms 1
• Atrophic vaginitis is more prevalent in breast cancer patients using aromatase inhibitors (18%) compared to those on tamoxifen (8%) 1
• May occur in premenopausal women who take antiestrogenic medications or who have medical or surgical conditions that result in decreased levels of estrogen 3

Diagnosis

• Clinical diagnosis is suggested by pruritus and erythema in the vulvovaginal area, often with a white discharge 1
• Diagnostic confirmation can be made when a woman has signs and symptoms of vaginitis and either:
  • Wet preparation (saline, 10% KOH) or Gram stain of vaginal discharge demonstrates thinning epithelium 1
  • Vaginal pH is typically elevated (>4.5), unlike in Candida vaginitis which has normal pH (<4.5) 1

Treatment Options

• Non-hormonal options:

  • Regular use of over-the-counter vaginal moisturizers can provide relief from dryness and discomfort 1
  • Water-based lubricants are recommended for use during sexual activity 1
  • Silicone-based products may last longer than water-based or glycerin-based products 1
  • Vaginal dilators can help with pain during sexual activity 1
  • Pelvic floor physical therapy can improve sexual pain, arousal, lubrication, and satisfaction 1
  • Regular sexual activity is helpful in maintaining a healthy, functional vagina 6

• Hormonal options (when non-hormonal options fail):

  • Vaginal estrogen therapy is the most effective treatment for vaginal dryness and associated symptoms, available in creams, tablets, and rings 1, 7
  • Low-dose formulations of vaginal estrogen minimize systemic absorption 1, 7
  • DHEA (prasterone) is FDA-approved for vaginal dryness and pain with sexual activity 1, 2

• Special considerations for breast cancer patients:

  • Non-hormonal options should be tried first 1, 2
  • If vaginal estrogen is needed, discuss risks and benefits with healthcare provider 1, 2
  • Estriol-containing preparations may be preferable for women on aromatase inhibitors 1, 2

Treatment with vaginal estrogen results in relief of symptoms in 80-90% of patients who complete therapy 1. Without treatment, symptoms of atrophic vaginitis typically worsen over time, unlike other menopausal symptoms 1, 2.