Atrophic vulvovaginitis

What is atrophic vulvovaginitis?

Atrophic vulvovaginitis means thinned genital tissues in women. Often it is shortened to atrophic vaginitis, as it is vaginal tissue that is most often symptomatic. Due its prevalence in older women, it is also known as senile vulvovaginitis.

What causes atrophic vulvovaginitis?

Atrophic vulvovaginitis is associated with oestrogen deficiency due to:

• Menopause
• Lactation
• Hyperprolactinaemia
• High-dose progesterone medicines
• Breast cancer medication, such as tamoxifen and aromatase inhibitors.

What are the symptoms of atrophic vulvovaginitis?

• Vaginal or vulval dryness
• Vaginal or vulval itching (pruritus vulvae)
• Vaginal burning
• Painful sex (dyspareunia)
• Skin splitting (fissuring) of the entrance to the vagina (posterior fourchette)
• Vaginal spotting (bleeding)

Deficiency of oestrogen may also lead to dysuria (burning sensation when passing urine), urinary urgency, frequency and incontinence (the genitourinary syndrome of menopause).

Bacteria in the vagina

Lack of oestrogen causes changes in the normal vaginal organisms. Those seen in younger women (especially lactobacilli) disappear and are replaced by gram negative organisms such as Escherichia coli or those associated with bacterial vaginosis. Urinary or bladder infections are more common in postmenopausal women than in younger women.

What does an atrophic vulva and vagina look like?

Atrophic vulvovaginitis changes the appearance of the female genitalia:

• Vulva appears paler
• Labia are thinner and smaller
• Clitoral hood is less obvious
• A red membrane or polyp may be visible at urethral opening (urethral caruncle)
• The vaginal skin looks thin and dry, with tiny blood vessels under it resulting in patchy redness
• Stretching the vulva may cause splitting of the skin at the bottom of the vagina or elsewhere.

Should any tests be done to confirm the diagnosis?

Tests may be performed in atrophic vulvovaginitis if any symptoms are present. These may include:

• Skin swab / wet mount examination – this may reveal epithelial cells typical of postmenopausal vagina may be reported and can help identify infection
• Biopsy – this may be done to make sure there is not an inflammatory skin disease or neoplastic condition causing symptoms
• Cystoscopy of the bladder and investigations for urinary symptoms
• Colposcopy of the vagina and cervix and investigations for gynaecological symptoms.

General measures to improve atrophic vulvovaginitis

The following measures are recommended:

• Use a non-soap cleanser or gently wash with warm water alone, no more than once or twice daily
• Apply emollient cream suitable for sensitive skin or petroleum jelly if the vulva feels dry or itchy
• Use a lubricant for sexual intercourse – if it stings, try another or use an oil or petroleum jelly
• A trial of a vaginal moisturiser
• Anticholinergic, antihistamine, decongestant or antidepressant medication may be contributing to dryness; if taking these, consider stopping
• Short-term use of topical steroid may be necessary for dermatitis caused by irritants such as urine, panty liner or tight clothing.

Oestrogen treatment

Atrophic vulvovaginitis is treated with topical oestrogen, a prescription medicine. This can be provided as vaginal cream, pessaries or vaginal ring. In New Zealand, Ovestin™, which contains oestriol, is used in a dose of 0.5 mg/day for 1–2 weeks then once or twice weekly. It can be inserted with an applicator or on a fingertip. Vagifem™ pessaries (containing oestrodiol) can also be used but are not currently funded by PHARMAC in New Zealand.

Oestrogen treatment results in:

• Normalisation of vaginal wall cells
• Improved vaginal blood flow
• Decreased vaginal pH
• Re-colonisation by lactobacilli
• Improve vaginal thickness and elasticity
• Reduction in vulvovaginal symptoms
• Improved sexual function
• Reduced urinary infections.

Topical oestrogen is considered safe because very little is absorbed systemically. However, it is not usually prescribed to women with severe liver disease, oestrogen-dependent cancers or thromboembolic disease in case it increases the risk of these conditions.

Other forms of oestrogen are sometimes recommended including tablets, transdermal patches, gels, sprays and emulsions. Systemic oestrogen is usually mixed with progestogens. There are important risks and side effects so they are not usually used if atrophic vaginitis is the only problem.

Side effects and risks of vaginal oestrogen therapy

Topical oestrogen may cause side effects, including:

• Vaginal itching and burning
• Increased risk of vaginal Candida albicans infection (vaginal thrush)
• Breast discomfort (uncommon)
• Vaginal bleeding (rare).

When used just once or twice weekly, other side effects described with higher doses or modes of delivery of oestrogen do not arise.

Other treatments for atrophic vulvovaginitis

Experimental options for vulvovaginal rejuvenation in symptomatic women that are unsuitable for or intolerant of local or systemic oestrogen therapy include:

• Platelet-rich plasma injections
• Hyaluronic acid or fat implants (lipofilling of labia majora)
• Fractional carbon dioxide laser, nonablative erbium:YAG laser, diode laser and monopolar radiofrequency devices
• Vaginal surgery (vaginoplasty).

Optimum regimens, effectiveness and safety of these procedures are as yet undetermined.