Atrophic vaginitis

Background

• Primarily occurs in peri or postmenopausal women
• Associated with conditions or medications that induce a low estrogen state such as:
  • Natural menopause
  • Bilateral oophorectomy
  • Spontaneous premature ovarian failure
  • Ovarian failure due to radiation or chemo
  • Medications: tamoxifen, danazol, medroxyprogesterone, leuprolide, ganirelix
  • Postpartum reduction in estrogen production
  • Prolactin elevation

Clinical Features

Symptoms are generally progressive and gradually worsen as women progress through menopause

• Vaginal dryness
• Vaginal burning/irritation
• Decreased vaginal lubrication
• Dyspareunia
• Vulvar or vaginal bleeding
• Vaginal discharge
• Pelvic pressure
• UTI symptoms

Differential Diagnosis

• Infection (candidiasis, bacterial vaginosis, trichomoniasis, desquamative inflammatory vaginitis)
• Reaction to irritants (soaps, deodorants, lubricants, clothing)
• Vulvovaginal lichen planus
• Vulvar lichen sclerosus
• If bleeding present, malignancy should be excluded

Vulvovaginitis

• Bacterial vaginosis
• Candida vaginitis
• Trichomonas vaginalis
• Contact vulvovaginitis
• Atrophic vaginitis
• Lichen sclerosus
• Tinea cruris
• Chlamydia/Gonorrhea infection

Evaluation

• History
  • Menstrual and medication history to assess for causes of hypoestrogenism
  • Complete ROS to rule out other causes of urogenital symptoms
  • Consider symptoms that may be secondary to infection, inflammation, local irritation
  • Ask about history of pelvic radiation
  • Thorough sexual history

• Pelvic Exam
  • External genitalia may show scarce pubic hair, diminished elasticity, introital narrowing, or fusion of labia minora
  • Loss of labial fat pad
  • Pale, dry epithelium that is smooth and shiny with loss of rugation
  • Use caution as exam can cause pain and bleeding
  • Assess for introital stenosis with gloved finger before inserting speculum

• Labs
  • Not usually necessary in ED unless concern for other causes

Management

• Topical estrogen cream or tablets
• Warm patients about possible side effects of breast or perineal pain and uterine bleeding
• Estrogen should not be used if history of cancer to reproductive organs or postmenopausal bleeding

Disposition

• Refer to gynecologist

References

Authors

Kristina Shigyo, Ross Donaldson, Neil Young, Daniel Ostermayer