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BASICS

  • Estrogen deficiency causes vulvovaginal atrophy and associated symptoms.
  • Also known as genitourinary syndrome of menopause (GSM) when postmenopausal.
  • Affects genital, urinary, and sexual health.

EPIDEMIOLOGY

  • Predominantly affects postmenopausal females (average menopause age ~51.3 years).
  • Prevalence: 40-54% in postmenopausal women; ~15% premenopausal women affected.
  • Underdiagnosed due to embarrassment and misconception symptoms are normal aging.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Estrogen is vasoactive, increasing blood flow and maintaining vaginal tissue health.
  • Deficiency leads to decreased blood flow, lubrication, elasticity, and thinning of vulvovaginal tissues.
  • Reduced glycogen → increased vaginal pH → impaired lactobacilli and normal flora.
  • Causes: natural or surgical menopause, premature ovarian failure (chemotherapy, radiation, autoimmune), postpartum, medications (GnRH agonists/antagonists, tamoxifen, aromatase inhibitors), elevated prolactin.
  • Sexual abstinence worsens atrophy; regular sexual activity may preserve vaginal epithelium.

RISK FACTORS

  • Smoking
  • Alcohol abuse
  • Sexual inactivity or decreased frequency
  • Lack of exercise
  • Absence of vaginal childbirth
  • Chemotherapy and radiation therapy

COMMONLY ASSOCIATED CONDITIONS

  • Urge and stress urinary incontinence
  • Pelvic organ prolapse
  • Recurrent urinary tract infections (UTIs)
  • Bacterial or fungal vulvovaginitis
  • Vaginal stenosis
  • Loss of libido and dyspareunia

DIAGNOSIS

History

  • Vaginal dryness, dyspareunia, pruritus, burning, pressure, tenderness.
  • Vaginal discharge (leukorrhea or malodorous).
  • Urinary symptoms: dysuria, hematuria, frequency, infections, incontinence.
  • Ask about radiation, medications, irritants, and self-treatments.

Physical Exam

  • Loss of pubic hair and vulvar elasticity.
  • Prominent urethral meatus; decreased secretions/lubrication.
  • Vulvar erythema or ecchymosis; decreased subcutaneous fat and moisture.
  • Pale, shiny, smooth vaginal and urethral epithelium with loss of rugation.
  • Vaginal shortening and intolerance to speculum exam.
  • Possible pelvic organ prolapse, urethral atrophy, Bartholin gland atrophy, cervical atrophy/stenosis.

DIFFERENTIAL DIAGNOSIS

  • Malignancy
  • Sexual trauma
  • Infection secondary to foreign bodies (e.g., piercings)
  • Dermatologic conditions: dermatitis, lichen sclerosus, lichen planus, bacterial/fungal vulvovaginitis

DIAGNOSTIC TESTS & INTERPRETATION

  • Clinical diagnosis primarily; biopsy if suspicion for dermatologic or oncologic disease.
  • Labs/imaging may include:
  • FSH and estrogen levels (high FSH, low estrogen in menopause)
  • Vaginal pH (usually >5 in estrogen deficiency)
  • Wet prep and urinalysis if infection suspected
  • Cytology: high parabasal cells, low intermediate/superficial cells

  • Transvaginal ultrasound: endometrial stripe <5 mm indicates estrogen loss

  • Medications may alter labs:

  • Estrogen therapy increases maturation index.
  • Tamoxifen and progestins may cause pseudo-menopausal state.

TREATMENT

General Measures

  • Wear loose-fitting clothing.
  • Avoid prolonged and scented pad use, deodorants, and douching.
  • Symptomatic relief: cool baths/compresses.
  • Increase coital activity to help maintain vaginal epithelium.
  • Smoking cessation.

Medication

Nonhormonal

  • Vaginal moisturizers and lubricants provide symptomatic relief but do not reverse atrophy.

Hormonal

  • Local vaginal estrogen therapy preferred for moderate to severe symptoms:
  • Vaginal cream (2-4 g daily 1-2 weeks → maintenance)
  • Vaginal estradiol tablets (10 µg nightly ×14 days → twice weekly)
  • Vaginal ring (2 mg, replaced every 3 months)
  • Systemic estrogen therapy reserved for vasomotor symptoms; use lowest effective dose for shortest time.
  • Contraindications: breast/estrogen-dependent cancers, undiagnosed bleeding, thromboembolism, liver disease, hypertension, coronary heart disease, smoking >35 years, migraines with aura.

Nonestrogen

  • Ospemifene (60 mg daily): selective estrogen receptor modulator for dyspareunia if estrogen contraindicated.

ISSUES FOR REFERRAL

  • Urogynecology for refractory urinary symptoms or pelvic organ prolapse.
  • Recurrent UTIs needing further evaluation.

ADDITIONAL THERAPIES

  • Fractional CO2 laser therapy shows promise but requires further study; not FDA approved.
  • Other agents under development: lasofoxifene, vaginal oxytocin gel.

ONGOING CARE

  • Follow up in 30-60 days to assess treatment response and adjust therapy.

DIET

  • Cranberry products may reduce UTI risk, though evidence is limited.

PATIENT EDUCATION

  • Postpartum lactating women (hypoestrogenic) should use lubricants and expect symptom resolution after breastfeeding ends.

PROGNOSIS

  • Good prognosis with vaginal estrogen replacement; symptoms generally improve.

COMPLICATIONS

  • Recurrent UTIs.
  • Increased susceptibility to vaginal infections due to atrophy.

REFERENCES

  1. Gandhi J, Chen A, Dagur G, et al. Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. Am J Obstet Gynecol. 2016;215(6):704-711.
  2. Johnston SL, Farrell SA, Bouchard C, et al. The detection and management of vaginal atrophy. J Obstet Gynaecol Can. 2004;26(5):503-515.
  3. Mitchell CM, Reed SD, Diem S, et al. Effectiveness of treatments for postmenopausal vulvovaginal symptoms: a randomized clinical trial. JAMA Intern Med. 2018;178(5):681-690.
  4. Ibe C, Simon JA. Vulvovaginal atrophy: current and future therapies (CME). J Sex Med. 2010;7(3):1042-1050.
  5. Suckling J, Lethaby A, Kennedy R. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2006;(4):CD001500.
  6. Constantine G, Graham S, Portman DJ, et al. Female sexual function improved with ospemifene in postmenopausal women with vulvar and vaginal atrophy: results of a randomized, placebo-controlled trial. Climacteric. 2015;18(2):226-232.

ICD10

  • N95.2 Postmenopausal atrophic vaginitis
  • E28.39 Other primary ovarian failure

Clinical Pearls

  • Estrogen deficiency affects some premenopausal women, not only postmenopausal.
  • Symptoms include vaginal dryness, urinary frequency, incontinence, recurrent UTIs, dyspareunia.
  • Vaginal moisturizers and lubricants are useful for mild symptoms; vaginal estrogen preparations preferred for moderate to severe symptoms.
  • Systemic estrogen used primarily for vasomotor symptoms; use lowest effective dose.