What is Vaginal Atrophy?
Vaginal atrophy, now often termed as genitourinary syndrome of menopause (GSM), is a condition that can also include vulvovaginal atrophy, urogenital atrophy, or atrophic vaginitis. In this discussion, we’re specifically talking about vaginal atrophy. This condition tends to happen mostly in postmenopausal women or women, regardless of age, whose levels of the hormone estrogen decrease, affecting the urogenital tissues – the tissues of the urinary and genital organs.
The signs and symptoms of vaginal atrophy are similar to many other conditions affecting the urinary and genital organs, which can sometimes lead to delayed diagnosis and treatment. It also brings changes to the structure (anatomy) and function (physiology) of these organs. Treating this involves correctly identifying the condition, using nonhormonal therapies, and sometimes needing hormonal treatments.
What Causes Vaginal Atrophy?
Estrogen, a hormone, plays a key role in keeping the urinary and genital systems healthy. This hormone interacts with receptors found in the vagina, vulva, urethra, and part of the bladder known as the trigone. This interaction helps to keep the blood flowing properly, maintain the thickness and flexibility of tissues, and keep these areas moist.
These healthy tissues support the presence of a type of good bacteria known as Lactobacilli, which feed on glycogen. Lactobacilli produce lactic acid, which lowers the pH in the vaginal area (3.5 to 5.0), creating an acidic environment. This acidity helps the Lactobacilli to survive and continue protecting against infections in the vagina and urinary tract.
In addition, sexual activities contribute to the renewal of cells in the vaginal area and the production of vaginal lubrication.
Vaginal ‘atrophy’ or thinning, drying and inflammation of the vaginal walls, usually happens when estrogen levels decrease. As the body’s production of estrogen diminishes, secretions also reduce, and the tissues in the genital and urinary systems start to thin and shrink, leading to different symptoms associated with this condition.
Aside from the decline in estrogen, other causes of vaginal atrophy include breastfeeding, lack of menstruation due to problems in the hypothalamus (a brain region controlling the menstrual cycle), and certain medicines, specifically those used for treating uterine fibroids and endometriosis, conditions related to the female reproductive system.
Risk Factors and Frequency for Vaginal Atrophy
Vaginal atrophy is a condition that can affect women at any stage, but it is more common among women after menopause. Studies show that about 15% of women have vaginal atrophy symptoms before menopause, while about 40% to 57% of women after menopause suffer from these symptoms. The significant drop in estrogen production triggered by menopause, which can be as much as 95%, often leads to this condition.
Regrettably, about 70% of women who experience these symptoms do not seek medical advice because they often feel embarrassed or consider these changes to be a normal part of aging. Likewise, cultural, religious, and societal beliefs can play a part in their reluctance. In most cases, women are unaware of existing treatments, resulting in less than 25% of women receiving care for this condition. This leads to it being both underdiagnosed and under-treated.
While postmenopausal women are the main group affected by vaginal atrophy, there are also other risk factors which can lower estrogen levels and result in early onset of the condition. These include:
- Women who have had surgery to remove both ovaries
- Women with primary ovarian insufficiency or ovarian failure due to radiation or arterial embolization
- Women with diseases affecting the hypothalamus-pituitary gland
- Women taking medications that reduce estrogen, such as leuprolide or danazol, which are often used for treating endometriosis
- Women who are breastfeeding after childbirth
- Breast cancer survivors who have experienced estrogen-lowering treatments such as chemotherapy or aromatase inhibitors
Signs and Symptoms of Vaginal Atrophy
Vaginal atrophy is sometimes hard to diagnose because its symptoms can be mistaken for other conditions, like urinary tract or vaginal infections. It’s important for doctors to obtain a complete medical and sexual history to help rule out these other causes. Patients may even avoid sexual activity due to uncomfortable changes, which could contribute to vaginal atrophy. The doctor should also inquire about past treatments, medication use, menstrual history, and any potential irritants. This would assist in the proper diagnosis of the condition. Otherwise, it might not be identified.
Patients with vaginal atrophy typically experience a number of symptoms such as:
- Vaginal dryness
- Burning sensation
- Irritation
- Pain during sexual intercourse (dyspareunia)
- Bleeding after sexual intercourse
- Unexpected vaginal bleeding
- Pain or discomfort while urinating (dysuria)
Decreased vaginal lubrication during sex and even during daily activities is a common early indicator. Moreover, the changing conditions in the vagina, such as alterations in pH and flora, can increase the chances of recurrent vaginal and urinary tract infections. If a woman experiences repeated genitourinary infection symptoms, the doctor should consider checking for vaginal atrophy.
Notes of physical changes in the vagina, like thinning pubic hair or changes in the labia’s shape, are also helpful in diagnosing this condition. During a pelvic exam, the doctor might note fragility, less elasticity, decreased lubrication, or changes in the vaginal vault’s size. The appearance of physical symptoms like paleness, redness, small red or purple spots, or increased visibility of blood vessels can all indicate atrophy. It may also be noted if there is brittleness, bleeding, or discharge.
Testing for Vaginal Atrophy
Your doctor might need to rule out infections in your urinary tract or genital area if you’re experiencing certain symptoms. Tests such as urinalysis, which involves examining your urine in a lab, or gathering cultures of cells from your pelvic area can help do this. They might also test for specific sexually transmitted infections using a urine antigen test, which finds proteins from harmful bacteria or viruses in your urine.
While measuring estrogen (a hormone) in the blood using a test called a serum estradiol could potentially help, it’s not very accurate, as current methods can’t detect the hormone at low levels very well.
What might be helpful is measuring your vaginal pH, which is a way of checking the level of acidity or alkalinity in your vaginal area. If your vaginal pH is above 5 and you don’t have any infections or unusual discharges, this could signal a problem.
There’s also an ongoing research involving what’s called a Maturation Index Test. This test examines the cells in the lining of your vagina. If there’s atrophy, which is a kind of wasting away or diminishing, there might be signs of shifting from superficial (surface-level) cells to basal (deeper) cells.
Treatment Options for Vaginal Atrophy
Vaginal atrophy, or thinning and inflammation of the vaginal walls, can be treated in a few different ways. These treatments can be grouped into non-hormonal and hormonal options.
Non-hormonal treatment involves using vaginal moisturizers and lubricants, which are considered first-line treatment. Lubricants can provide short-term relief and are often used for vaginal dryness during sexual activity. Moisturizers, on the other hand, have a longer-lasting impact and can be used daily or a few times a week. Engaging in safe, regular sexual activities can also be beneficial for maintaining the health of the vaginal lining and its natural bacteria.
As vaginal atrophy progresses, the internal environment of the vagina changes. So it’s important that any moisturizers or lubricants used have a pH balance and osmolality (concentration of dissolved particles) close to that of a healthy vagina. Using products that replicate the natural conditions of the vagina not only helps with symptoms, but may also reduce the chance of vaginal infections.
If these non-hormonal treatments don’t manage the symptoms effectively, hormone therapy might be necessary. This could include systemic hormonal replacement therapy (HRT), which involves oral estrogen replacement, or localized HRT, which could be topical estrogen, a vaginal ring that releases estrogen, or vaginal application of dehydroepiandrosterone (DHEA, a male hormone). Studies suggest that around 75% of cases improve with systemic HRT, while local therapy is effective in 80%-90% of cases. Local therapy is generally viewed as safer than systemic.
Local estrogen therapy is usually started at lower doses. It could involve vaginal creams which are typically applied daily, or vaginal tablets/capsules and vaginal rings for more precise estrogen dosing. Despite different forms, they are all equally effective in managing vaginal atrophy symptoms.
In most cases, HRT brings about improvement within 2 to 4 weeks of treatment, with continued response apparent after 12 weeks. The lowest dose can be continued indefinitely, with monitoring of risks and benefits.
Like every medication, HRT comes with risks as well as benefits, which should be discussed with the patient before starting the treatment. Those at higher risk include survivors of breast or endometrial cancer. While they can still use topical estrogen therapy, they should be aware of the increased sensitivity to even low levels of estrogen, which may raise their risk of recurrence or new cancer.
Systemic HRT is generally reserved for patients who have menopausal symptoms, like night sweats and hot flashes, alongside vaginal atrophy. This type of therapy, which includes estrogen-progestins, or just estrogen for women who’ve had a hysterectomy, can significantly aid vaginal health and increase lubrication.
Alternative treatments, particularly for those with a history of hormone sensitive cancer, may include selective estrogen receptor modulators (SERM). These have a beneficial effect on the vaginal lining without affecting estrogen dependent organs. More recently, laser and radiofrequency therapies have been introduced as treatment options. However, safety and efficacy of these methods need more confirmation.
Lastly, if vaginal atrophy has caused changes in the shape or size of the vagina, vaginal dilators may be useful. These are generally used only if estrogen therapy cannot be taken or if moisturizers and lubricants weren’t successful. Dilators have been shown to improve vagina function.
What else can Vaginal Atrophy be?
Some of the symptoms of vaginal atrophy are similar to symptoms of other vaginal conditions. This can make it harder for doctors to determine if vaginal atrophy is the sole cause. They usually have to consider and rule out other health problems. These may include:
- Infections in the vulva and vagina, such as yeast infections, bacterial vaginosis, and trichomoniasis.
- Sexually transmitted infections, like gonorrhea and chlamydia.
- Skin conditions that affect the vagina, including lichen planus, lichen sclerosis, or irritation due to something that causes inflammation.
- Conditions that look like a urinary tract infection or cancer.
It’s important to understand that even if these other health problems are present, it doesn’t mean that a woman doesn’t have vaginal atrophy. These conditions might just be additional issues that occur because of ongoing vaginal atrophy.
What to expect with Vaginal Atrophy
Women who are dealing with vaginal atrophy, a condition that causes the walls of the vagina to thin and dry, can experience noticeable relief for their symptoms if they receive treatment after an accurate diagnosis. However, if they do not get treated, these women will continue to suffer from ongoing symptoms. This ongoing discomfort can cause various problems, such as increased frustration, a lower quality of sex life, repeated infections, and a decrease in the overall quality of their lives.
Possible Complications When Diagnosed with Vaginal Atrophy
If vaginal atrophy is not recognized and addressed promptly, it can result in frequent infections of the urinary and genital system. Additionally, it can cause significant discomfort and pain in the vagina and pelvis.
- Frequent urinary and genital infections
- Significant vaginal and pelvic discomfort
- Vaginal and pelvic pain
Preventing Vaginal Atrophy
The signs of vaginal atrophy might not be clear or easily noticeable. Additionally, a lot of women don’t feel comfortable telling their healthcare provider about these symptoms. Therefore, it is important for patients not only to be checked for these symptoms during their routine health check-ups, but also to be informed about what signs to keep an eye out for, particularly in women who have gone through menopause. This way, patients can stay aware and be more comfortable sharing any symptoms they might have with their healthcare provider as soon as they come up.
