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Vaginal Atrophy

Definition:
Vaginal atrophy (atrophic vaginitis) is thinning and inflammation of the vaginal walls due to a decline in estrogen. Vaginal atrophy occurs most often after menopause, but it can also develop during breast-feeding or at any other time your body's estrogen production declines.

By some estimates, more than half of menopausal women experience vaginal atrophy, although very few seek treatment. The rest may resign themselves to the symptoms or be embarrassed to broach the topic with their doctors.

That's unfortunate, because the condition isn't trivial. For many women, vaginal atrophy makes intercourse painful. If intercourse hurts, your interest in sex will naturally wane — taking away an important source of joy in your relationship.

What's more, healthy genital function is closely intertwined with healthy urinary system function. When atrophic changes affect your urinary system as well as your vagina (genitourinary atrophy), you might also experience increased frequency or urgency of urination or burning with urination. Some women experience more urinary tract infections or incontinence.

The good news is that simple, effective treatments for vaginal atrophy are available. Reduced estrogen levels do result in changes to your body, but it doesn't mean you have to live with vaginal discomfort and associated urinary problems.

Causes:
Vaginal atrophy is caused by a loss of estrogen. Less circulating estrogen makes your vaginal tissues thinner, drier, less elastic and more fragile. Menopause is the most common cause of reduced estrogen levels that result in vaginal atrophy.

In premenopausal women, estrogen levels are generally high enough to maintain the normal elasticity and thickness of vaginal tissue. But a drop in estrogen levels and vaginal atrophy may occur in other circumstances, including.

  • During breast-feeding
  • After surgical removal of both ovaries (surgical menopause)
  • After pelvic radiation therapy for cancer
  • After chemotherapy for cancer
  • As a side effect of breast cancer hormonal treatment

Vaginal atrophy due to menopause may begin to bother you during the years leading up to menopause (perimenopause), or it may not become a problem until several years into menopause. Although the condition is common, not all menopausal women develop vaginal atrophy. Regular sexual activity helps you maintain healthy vaginal tissues.

Risk Factor:
Certain factors may contribute to vaginal atrophy. Among these are:
  • Smoking. Cigarette smoking impairs blood circulation, depriving the vagina and other tissues of oxygen. Decreased blood flow to your vagina contributes to atrophic changes. Smoking also reduces the effects of naturally occurring estrogens in the body. In addition, women who smoke have an earlier menopause and are less responsive to estrogen therapy in pill form.
  • Decreasing levels of hormones other than estrogen. After removal of the ovaries, lower levels of androgens such as testosterone may lead to vaginal atrophy. Women who have had their ovaries removed and experience symptoms of vaginal atrophy despite adequate estrogen therapy may benefit from testosterone replacement.
  • Never giving birth vaginally. Researchers have observed that women who have never given birth vaginally are more prone to vaginal atrophy than are women who have had vaginal deliveries.
When to seek medical advice:
Make an appointment to see your doctor if you experience painful intercourse that's not resolved by using a vaginal moisturizer (Replens, others) or water-based lubricant (Astroglide, K-Y, others), or if you have vaginal symptoms, such as unusual bleeding, vaginal discharge, burning or soreness.

Symptoms:
It's possible to have vaginal atrophy without any signs or troublesome symptoms. But with moderate to severe vaginal atrophy, you may experience:
  • Vaginal dryness
  • Vaginal burning
  • Watery vaginal discharge
  • Burning with urination
  • Urgency with urination
  • More urinary tract infections
  • Urinary incontinence
  • Light bleeding after intercourse
  • Discomfort with intercourse

You might feel as if your vagina is smaller, and that could, quite literally, be the case. Vaginal atrophy can result in a vaginal canal that's shorter and narrower.

Dignosis:
Your doctor will ask questions about the symptoms you're experiencing and assess your hormonal status. Expect to have a complete pelvic exam. During the pelvic exam, your doctor checks for signs of vaginal atrophy and pelvic organ prolapse, indicated by bulges in your vaginal walls from pelvic organs such as your uterus or bladder.

Your doctor may take a sampling of cells from your vagina to be studied under a microscope. He or she also may also place a paper indicator strip in your vagina to test its acidity.

Complications:
With vaginal atrophy, your risk of vaginal infections (vaginitis) increases. Atrophy leads to a shift in the acidic environment of your vagina, which makes you more susceptible to infection with bacteria or other organisms.

As the lining gets thinner, you're at risk of developing open sores or cracks in the walls of your vagina. Such sores can develop from friction or injury to the vaginal walls or from recurrent vaginal infections.

Atrophic vaginal changes are also associated with changes in your urinary system and function (genitourinary atrophy), which can contribute to urinary problems. You might experience increased frequency or urgency of urination or burning with urination. Some women experience more urinary tract infections or incontinence.

Treatment:
If you don't have vaginal discomfort, you might not need treatment for vaginal atrophy. However, if you have vaginal atrophy and you're bothered by vaginal dryness, vaginal irritation, discomfort with intercourse, urinary frequency or urinary urgency, effective treatments are available.

The most effective treatment is estrogen applied topically to the vaginal area, usually in the form of a cream. Slow-releasing vaginal suppositories or rings are another option. A vaginal ring remains in place for up to three months to provide longer term relief. These treatments are referred to as local estrogen therapy.

With local estrogen therapy, the estrogen stays primarily in the vaginal tissues. Early in the course of treatment, you may absorb some estrogen into your bloodstream. But as your vaginal tissues become healthy again, estrogen absorption into your bloodstream is minimal. Doses are kept low to avoid unintended systemic effects. However, it's important not to exceed the dosage of estrogen your doctor recommends. Properly prescribed and used, local estrogen therapy isn't thought to carry the long-term risks associated with systemic estrogen therapy.

Systemic estrogen treatment — by pill, patch or gel — may be the best choice if other problems associated with estrogen deprivation, such as hot flashes or sleep deprivation, are troublesome. Systemic estrogen can sometimes provide adequate relief for vaginal atrophy, but often local estrogen therapy is needed in addition. If you have your uterus, systemic estrogen treatment requires treatment with a progestin as well to avoid overgrowth of your uterine lining.

Unlike estrogen therapy in pill or patch form (systemic), topically applied estrogen doesn't usually affect the uterine lining, so concurrent progestin treatment is rarely necessary.

You should experience noticeable improvements after a few weeks of estrogen therapy. Some symptoms of severe atrophy may take longer to resolve.

Prevention:
Regular sexual activity, either with or without a partner, can decrease problems with vaginal atrophy. Sexual activity enhances blood flow to your vagina, which helps keep vaginal tissues healthy.
 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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