Clinical Signs of Vulvovaginal Atrophy
Vulvovaginal atrophy presents with visible vaginal and vulvar changes including vaginal pallor, loss of rugae, thinning of the vaginal epithelium, erythema, petechiae, increased vaginal pH (>4.5), and a thin white discharge, often accompanied by pruritus and dryness of the vulvovaginal tissues. 1, 2
Physical Examination Findings
Vaginal Changes
- Thinning of the vaginal epithelium is the hallmark finding, visible on speculum examination as loss of the normal thick, rugated appearance 2, 3
- Vaginal pallor (pale appearance) replaces the normal pink, moist tissue due to decreased vascularity 2, 3
- Loss of vaginal rugae (the normal folds) creates a smooth, shiny vaginal surface 2, 3
- Vaginal erythema and petechiae may be present, indicating friable tissue that bleeds easily 2
- Vaginal stenosis or narrowing can develop, particularly in women who have undergone pelvic radiation 1
Vulvar Changes
- Vulvar erythema with pruritus is commonly observed 2
- Loss of labial fullness and thinning of vulvar tissues occur due to decreased collagen 3
- Clitoral hood retraction may be visible 3
Laboratory Findings
- Elevated vaginal pH (>4.5) is a key diagnostic finding, contrasting with the normal premenopausal pH of <4.5 2
- Wet preparation or Gram stain demonstrates thinning epithelium with decreased superficial cells 2
- Maturation index shows a shift toward parabasal cells rather than superficial cells 3
Associated Discharge
- Thin white discharge may be present, though not purulent 2
- The discharge is typically minimal compared to infectious vaginitis 2
Urogenital Findings
- Urethral caruncle or prolapse may be visible at the urethral meatus 3
- Loss of urethral support can be appreciated on examination 3
- Bladder base descent may be noted during pelvic examination 3
Important Diagnostic Considerations
Confirming the Diagnosis
The diagnosis is primarily clinical, based on the constellation of physical findings in a postmenopausal or estrogen-deficient woman. 2, 3 The combination of symptoms (vaginal dryness, dyspareunia, urinary urgency) with objective signs (elevated pH, thin epithelium, loss of rugae) establishes the diagnosis. 1, 2
Common Pitfall
Do not confuse vulvovaginal atrophy with infectious vaginitis. Unlike Candida vaginitis, which has a normal pH (<4.5), atrophic vaginitis has elevated pH (>4.5). 2 The presence of Candida in asymptomatic women (10-20% of normal women) should not prompt treatment. 2
Severity Assessment
- Mild atrophy: Minimal loss of rugae, slight pallor, pH 4.6-5.0 3
- Moderate atrophy: Obvious thinning, visible erythema, pH 5.1-6.0 3
- Severe atrophy: Marked pallor, petechiae, friable tissue, stenosis, pH >6.0 3
The severity of physical findings does not always correlate with symptom severity, so both objective signs and subjective symptoms must guide treatment decisions. 3, 4