Atrophic vaginitis

Overview

Atrophic vaginitis (genitourinary syndrome of menopause, GSM) - caused by oestrogen deficiency leading to thinning, drying, and inflammation of vaginal and urethral tissues. Chronic and progressive; does not improve without treatment.

Presentation

•Vaginal dryness - most common symptom

•Dyspareunia - superficial pain; may cause post-coital bleeding

•Vulval/vaginal soreness or burning - from epithelial thinning and inflammation

•Vaginal discharge - thin, watery, or pale yellow; altered flora due to raised pH

•Urinary symptoms - urgency, frequency, dysuria, recurrent UTIs

•Postmenopausal bleeding - friable epithelium; always investigate to exclude malignancy

•Examination - pale, smooth vaginal mucosa, loss of rugae, narrowed introitus, bleeds on contact; vaginal pH >5.0

🚨

Postmenopausal bleeding must always be investigated to exclude endometrial carcinoma - refer urgently (2-week wait) for unexplained postmenopausal bleeding.

Investigations

•Primarily a clinical diagnosis in a postmenopausal woman with characteristic history and examination

•Vaginal pH testing - pH >5.0 supports atrophy; low pH points to Candida or physiological discharge

•High vaginal swab (HVS) - to exclude BV, Candida, Trichomonas if infection suspected

•Urine dipstick and MSU - if urinary symptoms prominent, to exclude concurrent UTI

🏆 Gold standard

•pelvic ultrasound and/or endometrial biopsy - indicated if postmenopausal bleeding present to exclude endometrial pathology

Management

•First-line (non-hormonal): vaginal moisturisers (e.g. Replens, Yes VM) - applied regularly, not just before intercourse; suitable when oestrogen is contraindicated

•First-line (symptomatic relief): vaginal lubricants (e.g. Yes WB, Sylk) - water-based, used during intercourse; do not treat underlying atrophy

•First-line (most effective): topical vaginal oestrogen - minimal systemic absorption, no progestogen required

•Estradiol pessaries (Vagifem 10 micrograms) - nightly for 2 weeks, then twice weekly

•Estriol cream (Ovestin)

•Estradiol vaginal ring (Estring) - replaced every 3 months

🥈 Second-line

•systemic HRT - when vasomotor symptoms also require treatment; combined oestrogen-progestogen if intact uterus, oestrogen alone post-hysterectomy

•Second-line (alternative): ospemifene - oral SERM licensed for dyspareunia in GSM where topical oestrogen cannot be used; vaginal agonist, breast antagonist

🥉 Third-line

•referral to gynaecology or menopause specialist - refractory symptoms, postmenopausal bleeding, complex HRT decisions

💡

Topical vaginal oestrogen is safe in most women including many breast cancer survivors due to minimal systemic absorption. Women on aromatase inhibitors should discuss use with their oncologist.

Follow-up

•Review at 3 months to assess treatment response

•Symptoms may take 4-12 weeks to fully improve with local oestrogen

•Local oestrogen safe to continue long-term - no endometrial stimulation at standard doses; routine endometrial surveillance not required

•Advise women to return promptly for any postmenopausal bleeding regardless of treatment