What is Atrophic Vaginitis?
Genitourinary syndrome of menopause is a collection of long-term conditions that tend to get worse over time and occur due to low levels of estrogen. These conditions include thinning and inflammation of the vaginal tissues, bladder, and urethral problems. The affected tissues, which form from the same embryonic tissues, grow and mature in response to estrogen. When there’s not enough estrogen, these tissues can change. This happens because the lining of the vagina (epithelium) thins out, the folds and elasticity of the vagina decrease, and the amount of vaginal secretions drop. Inflammatory changes in the thinned vaginal lining, a condition known as atrophic vaginitis, can cause symptoms in some women before menopause, and in up to 50% of women after menopause.
What Causes Atrophic Vaginitis?
A hypoestrogenic state refers to having low levels of estrogen, which is a hormone in the body. This can be part of the natural process of menopause, or it can be caused by certain treatments such as surgery, radiation, or chemotherapy. Sometimes, premenopausal women who are breastfeeding can temporarily experience low estrogen levels.
There are a variety of other conditions that can lead to low estrogen. For instance, certain drugs, radiation therapy, chemotherapy, or issues with the hypothalamus, a part of the brain that controls hormones, can also cause this. Some of the medications that can lead to low estrogen include selective estrogen receptor modulators, selective estrogen receptor degraders, and antigonadotropins.
Having low estrogen levels can lead to changes in the vaginal environment. This typically includes a reduction in the normal bacteria, specifically Lactobacillus spp. With fewer of these bacteria, other disease-causing bacteria from the skin and rectal areas can grow more easily.
Risk Factors and Frequency for Atrophic Vaginitis
Between 10% and 50% of women who have gone through menopause can develop a condition called atrophic vaginitis. Also, 15% of women who haven’t experienced menopause can develop symptoms of a condition called genitourinary syndrome. However, these conditions could be even more common than we know because many women do not talk about their symptoms.
Signs and Symptoms of Atrophic Vaginitis
Postmenopausal women are usually above the age of 50, unless they experience early menopause due to certain conditions or treatments. After menopause, women often have low levels of estrogen, the hormone that helps maintain the health of the reproductive system. This decrease in estrogen can result in a range of uncomfortable symptoms, often referred to as the genitourinary syndrome. The symptoms may appear anytime from early to late postmenopause. Healthcare providers often use the STRAW staging system to evaluate a woman’s transition through menopause and postmenopause.
The symptoms of atrophic vaginitis (a common condition in postmenopausal women) can include:
- Dryness in the vulva and vagina
- Itching (pruritis)
- Pain during sexual intercourse (dyspareunia)
- Abnormal vaginal discharge
- Pain during or after sexual intercourse in the labia minora or deeper in the vaginal vault
- Recurrent urinary tract infections
- Pain in the urethra
- Presence of blood in the urine (hematuria)
- Loss of bladder control (urinary incontinence)
The severity and progress of these symptoms can vary widely among individuals. Some women may notice these changes gradually, while others may find them quite sudden.
Testing for Atrophic Vaginitis
As we age, the hair on our body starts to thin out and lose its color. This also leads to a reduction in the fat beneath the skin, causing areas such as the pubic mound and the external female genital region to decrease in size. Women may notice cracks or signs of rubbing on the outer genitals or at the vaginal opening. Certain skin changes might occur, such as red patches possibly accompanied by tiny red spots or easily damaged tissue.
For doctors to assess these changes, they may perform a number of checks before a physical examination using a device called a speculum. These tests can include measuring the pH level of the vagina, taking samples of vaginal discharge for analysis, and performing cultures to check for bacteria or other microorganisms.
The physical examination can then reveal issues such as reduced estrogen levels, which is indicated by thinning and dryness of vaginal tissues, and a narrower vaginal opening. This lack of estrogen can lead to the vaginal tissue appearing pale pink with lesser vaginal secretions. A pH level above 5.0 or a reduced Follicular stimulating hormone level usually means lowering estrogen levels.
A key measure of vaginal health is the Vaginal Maturation Index (VMI), which is the balance between different types of cells in vaginal tissue. Reduced estrogen levels can lead to an increase in one type of cell, called parabasal cells, resulting in a lower VMI. To classify estrogen levels visually, a VMI score of 0 to 49 indicates low estrogen level while a score of 65 to 100 indicates high estrogen level.
Treatment Options for Atrophic Vaginitis
The treatment of atrophic vaginitis, or inflammation of the vagina due to thinning and shrinking tissues, often starts with a trial of estrogen applied directly into the vagina. Several types of estrogen, like conjugated estrogen cream or estradiol tablets, can help alleviate symptoms and make the tissues in the vagina healthier. It’s important to use the smallest effective amount to limit the amount of estrogen that enters your system. Once your symptoms improve, the dose of estrogen can be gradually reduced. Some people may need to continue treatment indefinitely.
However, not everyone can use estrogen therapy. People who have certain types of cancer – like estrogen receptor-positive breast cancer, blood clot disorders, liver disease, unexplained vaginal bleeding, certain illnesses affecting the womb, heart disease, pregnancy, certain types of migraines, or an allergy to estrogen or its delivery system should not use estrogen therapy.
You can measure how well the estrogen is working by examining the maturation index, a clinical measurement of your vaginal tissues. The presence of a type of bacteria called lactobacillus in your vagina is a good sign: it’s linked to fewer genital symptoms compared to a change in pH.
If you can’t or don’t want to use estrogen treatments, there are several other options available. Selective estrogen receptor modulators, tissue-selective estrogen complexes, estriol, platelet-rich plasma, herbal treatments, and other natural products may provide relief. One particular selective estrogen receptor modulator, ospemifene, is approved by the FDA to manage painful sex (dyspareunia) or for those who aren’t suitable candidates for estrogen therapy.
People may also use lubricants to improve symptoms if they can’t use estrogen therapy. These can relieve symptoms, but will not cause any changes on a cellular level. Other non-hormonal options such as laser therapy and a treatment called transcutaneous temperature-controlled radiofrequency might help improve vaginal dryness, looseness, and dyspareunia for 6-12 months.
What else can Atrophic Vaginitis be?
There are many conditions that can cause similar symptoms to the one you’re experiencing. These include:
- Vaginal thinning (also known as vaginal atrophy)
- Thinning and inflammation of the skin in the vaginal and vulvar area (vulvovaginal atrophy)
- A type of inflammation of the skin in the vaginal and vulvar area, known as vulvovaginal lichen planus or sclerosis
- An inflammation of the skin around the vagina, known as vulvar dermatitis
- A fungal infection in the vaginal area, known as vulvovaginal candidiasis
- Vulvodynia which is chronic pain in the area around the opening of the vagina
- Inflammation of the vagina, without thinning of the tissue (inflammatory vaginitis without atrophy)
- Inflamed and peeling (desquamative) inflammatory vaginitis
- A growth or tumor in the vaginal and vulvar area (vulvovaginal neoplasm)
- Sexually transmitted infections
- Other types of infections
- Issues related to the urinary or genital system (urogenital dysfunction)
Remember, these are just possibilities. If you experience any unusual or discomforting symptoms, always consult with a healthcare provider to get a confirmed diagnosis.
What to expect with Atrophic Vaginitis
Intravaginal estrogen has been seen to improve conditions for many women. However, for those who do not respond to this treatment or only see partial resolution, additional treatment with a medication called ospemifene may be started.
Certain factors can increase the risk of needing this treatment. For example, women who have not given birth vaginally may be at a higher risk since their vaginal canal has not been stretched. Additionally, cigarette smoking can exacerbate symptoms since it causes the blood vessels to become narrower, leading to decreased secretions.
Possible Complications When Diagnosed with Atrophic Vaginitis
If atrophic vaginitis isn’t treated, it can lead to ongoing itching. This could result in scarring due to constant scratching. Moreover, thinning of the vaginal lining might cause small cuts or tears. Additionally, the patient could keep experiencing various urinary system issues.
Preventing Atrophic Vaginitis
Atrophic vaginitis is a type of inflammation linked to low levels of the hormone estrogen. Women before menopause might experience symptoms that are usually found in women after menopause. The usual treatment begins with localized estrogen therapy to relieve symptoms. Additional treatments using estrogen modulator receptors or radiofrequency treatment could help improve symptoms even more.
