What is vaginal atrophy?
Vaginal atrophy (also called atrophic vaginitis) is a condition where the lining of the vagina gets drier and thinner. This results in itching, burning and pain during sex, among other symptoms. The condition also includes urinary tract problems such as urinary tract infections (UTIs) and frequent urination. Vaginal refers to the vagina while atrophy means “a wasting away or diminution.” Recently, the term vaginal atrophy has been replaced with the newer term, genitourinary syndrome of menopause (GSM). This new term helps describe not just the vaginal, but also the urinary symptoms that can be accompanied by the effects of low estrogen.
Vaginal atrophy most often occurs during menopause, the “change of life.” This happens because of a decrease in the hormone estrogen. It can occur in younger women, as well, when their estrogen levels are affected.
Hormones are produced, stored and secreted by the endocrine system, a network of glands and organs. Women need the hormone estrogen for good health, especially during the child-bearing years. When menopause happens around age 50, the ovaries produce fewer hormones and the woman stops having a monthly period. There are many uncomfortable symptoms for women during that time, and that includes vaginal dryness and other symptoms that might indicate vaginal atrophy.
What’s the difference between vaginal atrophy (atrophic vaginitis) and a yeast infection?
Both vaginal atrophy and yeast infections can have symptoms of dryness, itching, redness and pain. However, vaginal atrophy is caused by a lack of estrogen while a vaginal yeast infection is caused by a fungal infection. Consult with your healthcare provider regarding symptoms so that you, together, can determine what condition you have.
Who is at risk for getting vaginal atrophy (atrophic vaginitis)?
Women age 50 and over, in menopause, are the most likely to experience vaginal atrophy. Other factors that increase your likelihood of developing vaginal atrophy include:
- Lack of sexual intercourse.
- Decreased ovarian functioning due to chemotherapy or radiation.
- Immune disorders.
- Medications that contain antiestrogen properties including Tamoxifen (Nolvadex), Medroxyprogesterone (Provera) and Nafarelin (Synarel).
- Nonfluctuating estrogen levels.
- Oophorectomy (removal of the ovaries).
- Postpartum loss of placental estrogen.
How common is vaginal atrophy (atrophic vaginitis, GSM)?
At least half of women who enter menopause suffer from signs and symptoms of genitourinary syndrome of menopause.
Symptoms and Causes
What causes vaginal atrophy (atrophic vaginitis)?
During menopause, your body makes less estrogen. Without estrogen, the lining of the vagina can become thinner and less stretchy. The vaginal canal can also narrow and shorten. Less estrogen lowers the amount of normal vaginal fluids. It also changes the acid balance of the vagina. Women who have just had a baby and are breastfeeding also have a drop in estrogen. These symptoms also occur in women who have had their ovaries removed or are taking certain medications (such as aromatase inhibitors for breast cancer treatment).
The first sign of vaginal atrophy is usually a decrease in vaginal lubrication.
What are the symptoms of vaginal atrophy (atrophic vaginitis)?
Symptoms of vaginal atrophy can include:
- Dryness of the vagina.
- Burning and/or itching of the vagina.
- Dyspareunia (pain during sex).
- A discharge from the vagina – usually a yellow color.
- Spotting or bleeding.
- Vulvar itching (pruritus).
- Feeling of pressure.
It can also affect your urinary system and cause symptoms. These include:
- Going to the bathroom often.
- Having pain when going to the bathroom.
- Urinary tract infections (UTIs).
- Urinating more.
- Stress incontinence.
- Painful urination (dysuria).
- Blood in the urine (hematuria).
- Burning during urination.
Diagnosis and Tests
How is vaginal atrophy (atrophic vaginitis) diagnosed?
The healthcare provider can diagnose vaginal atrophy based on your symptoms and a pelvic exam to look at how the vagina appears. It will help to know whether or not you are in menopause. Classic signs of atrophy during a pelvic exam include:
- A shortened or narrowed vagina.
- Dryness, redness and swelling.
- Loss of stretch in the skin.
- Whitish discoloration to the vagina.
- Sparsity of pubic hair.
- A bulge in the back wall of the vagina.
- Vulvar skin conditions (dermatoses), vulvar lesions and/or vulvar patch redness (erythema).
- A bladder that has sagged into the vagina.
- Urethral lesions.
- Minor cuts (lacerations) near the vaginal opening.
What tests are done to diagnose vaginal atrophy (atrophic vaginitis, GSM)?
The vast majority of the time, a trained clinician can easily diagnose atrophic and GSM changes with a careful physical exam. Occasionally laboratory tests are required to differentiate vaginal atrophy from other conditions such as:
- Pap test.
- Urine sample.
- Serum hormone testing.
- Vaginal pH.
What questions might my healthcare provider ask to diagnose vaginal atrophy (atrophic vaginitis, GSM)?
- Are you in menopause?
- What medications are you taking?
- Did you recently have a baby?
- Is vaginal intercourse painful?
- Have you tried over-the-counter lubricants or moisturizers?
- Have you noticed any discharge?
- Have you been bleeding or spotting?
- How long have you noticed these symptoms?
Experts have observed that vaginal atrophy may be underdiagnosed. Mention it to your healthcare provider if you think your symptoms may match vaginal atrophy.
Management and Treatment
How is vaginal atrophy (atrophic vaginitis) treated?
You and your healthcare provider will work closely together to come up with a treatment plan for vaginal atrophy. They’ll help you decide which plan is most effective based on your symptoms and the severity of them. Estrogen therapy is considered to be the most effective.
Some treatments are meant to treat the symptoms of atrophy. Others address the loss of estrogen, specifically, which will also act to relieve symptoms.
- Lubricants and moisturizers to add moisture and to loosen the vagina can treat dryness. This improves comfort during sex. The moisturizers won’t completely restore the health of the vagina. Multiple brand names are available over-the-counter. Some are vaginal moisturizers for irritation and dryness throughout the day, similar to a skin moisturizer (Replens, Hyalofemme, Silk-E, and others). Others are personal lubricants best used during sexual activity (Astroglide, Uber Lube, Condom-Mate suppository, Today brand personal lubricant, K-Y liquid formula). Vaseline is NOT recommended for use inside the vagina because it can lead to yeast infections. Though many women use olive or coconut oils as a moisturizer and lubricant, occasionally this may cause an allergic irritation in the vaginal area. Vitamin E and mineral oils should be avoided.
- Dilators are devices to widen (dilate) the vagina to enable you to go back to having sex. Women often start with a narrow dilator and move on to larger sizes over time. This is done until the vagina is wide enough to fit a penis for sexual activity without pain. The best results are obtained when dilators are used in conjunction with local hormone therapy.
- Hormone therapy not only improves symptoms of vaginal atrophy the best, but also brings back the health of the skin by restoring the normal acid balance of the vagina, thickening the skin (back to how it was originally), maintaining natural moisture and improving bacterial balance. Over the counter repHresh vaginal gel can also be used to help restore normal vaginal pH. Douching should be avoided.
What are the hormonal treatment options?
Luckily, for women who are only having vaginal atrophy symptoms, there are several options that allow estrogen to be delivered only to the vagina. These options can help to avoid high hormone levels in the rest of the body. Women who are having multiple other menopausal symptoms — such as hot flashes and difficulty sleeping — may choose to use hormone therapy at higher doses to treat all of their symptoms (referred to as systemic hormone therapy). The local vaginal hormone options will not treat any menopausal symptoms besides the vaginal ones.
- Vaginal low-dose estrogen therapy (local therapy). These formulations are meant to treat only vaginal symptoms, as they are not being absorbed by the rest of the body. They are available in the forms of a cream (two types, estradiol or conjugated estrogens), a vaginal pill/suppository, or a ring which is left in the vagina for three months. After three months, the old ring is removed and a new one is inserted. Many women confuse vaginal estrogen only forms of treatment with systemic hormone therapy, and unnecessarily worry about risks of blood clots, heart disease, etc.
- Systemic hormone therapy (also called hormone replacement therapy). This is taken in higher doses that go to other cells of the body, not just to the vagina. If you are more than 10 years past menopause, or only have vaginal symptoms, you will more likely be using local therapy. However many women on systemic hormone therapy benefit from improved bone health, vaginal health, better sleep, less hot flashes and improved mood, among other health benefits. You should discuss with your doctor whether systemic hormone therapy is right for you.
- Ospemifene (Osphena) is the first non-estrogen pill that is taken by mouth daily with food. Its benefits to the vagina are similar to that of estrogen. Serious but uncommon side effects can include blood clots and stimulation (thickening) of the lining of the uterus. Some women may also notice more hot flashes, vaginal discharge and muscle spasms, though the majority of women will have no symptoms.
Mild symptoms can usually be managed with over-the-counter options. Prescriptions are available for moderate to severe symptoms.
Sexual activity should not be avoided if you have vaginal atrophy. A lack of sexual activity actually worsens the condition. Sex stimulates blood flow in the vagina and aids in the production of fluids so, therefore, sex actually keeps the vagina healthy.
Are there complications/side effects of treatment?
Pay attention to any new symptoms that come after you start treatment. These could be irritation to the skin, more pain and/or discharge. Discuss any possible side effects with your healthcare provider. Don’t hesitate to consult your healthcare provider if you’re uncomfortable!
Can vaginal atrophy (atrophic vaginitis) be prevented?
A woman’s body naturally secretes less estrogen with age. This cannot be prevented. Without intervention, it’s unlikely that the ovaries will make more of the hormone.
However, there are ways to keep vaginal atrophy from getting worse. Avoid tight-fitting clothing, panty liners, perineal pads and any of the following that you may find irritating to your vagina:
Outlook / Prognosis
What can I expect if I’ve been diagnosed with vaginal atrophy (GSM)?
You don’t have to just “live with” vaginal atrophy. Even if you’re in menopause or postmenopausal, that doesn’t mean you should have to deal with UTIs, endure itching or burning, or painful sex. Treatment not only helps with symptoms, but it helps restore a healthy pH and bacterial balance back to your vagina.
Can vaginal atrophy (atrophic vaginitis, GSM) be cured?
You don’t have to live with the discomfort of vaginal atrophy. With proper diagnosis and treatment, the symptoms can be managed.
Can vaginal atrophy (atrophic vaginitis) get worse?
Be sure to address your symptoms quickly with your healthcare provider. The sooner you get treatment, the less likely it is that your vaginal atrophy will worsen. For example, the longer you go without estrogen, the dryer the vagina will become. Without treatment, yes, your vaginal atrophy may get worse. Occasionally, atrophy can become so severe that it can significantly narrow the vaginal opening. This may make it harder to treat the atrophy if treatment is initiated too late.
What is it like living with vaginal atrophy (atrophic vaginitis)?
Vaginal atrophy can seriously affect your quality of not just your sex life, but life in general. The pain, dryness, burning/itching, spotting, bleeding, urinary problems, UTIs and discharge can make you very uncomfortable and interfere with your daily living. One in four women report that vaginal atrophy has had a negative impact on other areas of their lives including their sleep, sexual health and general happiness.
How do I take care of myself?
Prioritize your sexual health as much as any other aspect of your health. Look to your healthcare provider for answers to any questions and concerns. Take your over-the-counter medications and prescriptions exactly as directed.
When should I see my healthcare provider for vaginal atrophy (atrophic vaginitis)?
Even if you’re not menopausal, be sure to report any symptoms of dryness, pain, burning/itching, urinary problems, UTIs, unusual spotting or bleeding or discharge to your healthcare provider. If weeks go by and the over-the-counter medications you’re using for dryness don’t work, you should see your healthcare provider then. If you see unusual discharge or bleeding, that’s also a reason to see your healthcare provider. Also, always see your healthcare provider for any symptoms that negatively impact your daily life.
What questions should I ask my healthcare provider?
- What over-the-counter options do you recommend for me?
- What prescriptions do you recommend for me?
- Is my condition temporary?
- Are there other ways to treat my condition?
- Are there any risks of treatment?
- How long will it be before the treatments work?
- Do I have another condition on top of the vaginal atrophy?
- What else can I do to stop the vaginal atrophy from worsening?
- What can my partner do to help?
A note from Cleveland Clinic
Vaginal atrophy is serious for menopausal women. It affects your quality of life with discomfort, frequent bathroom trips, frequent UTIs, burning, pain with sex and more. Fortunately, there are many treatments and your healthcare provider can help you find the best option for your symptoms.
Seek treatment. Don’t be afraid to have the conversation with your healthcare provider and with your partner. Always follow your healthcare provider’s instructions and do what you can to prevent vaginal atrophy from getting worse!
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