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

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