- Patho/Etiology
- Caused by a significant decrease in estrogen levels, which leads to thinning (atrophy) of the vaginal epithelium and vulvar skin.
- Reduced estrogen impairs vaginal epithelial cell maturation and glycogen production. This leads to a loss of Lactobacilli, an increase in vaginal pH (>4.5), and reduced mucosal secretions.
- Primarily affects postmenopausal women but can also occur with breastfeeding, oophorectomy, or use of anti-estrogenic medications (e.g., SERMs, aromatase inhibitors).
- Clinical Presentation
- Vaginal Symptoms: Dryness, burning, itching, dyspareunia (painful intercourse), and postcoital spotting due to tissue friability. A thin, yellowish, or malodorous discharge may be present.
- Urinary Symptoms (Urogenital Atrophy): Dysuria, urinary frequency/urgency, and recurrent UTIs due to atrophy of the urethral and bladder trigone epithelium.
- Physical Exam: Pale, dry, smooth vaginal mucosa with loss of rugae; sparse pubic hair; vulvar erythema and petechiae; potential urethral caruncle.
- Diagnosis (Dx)
- Primarily a clinical diagnosis based on characteristic symptoms and physical exam findings in a hypoestrogenic woman.
- Vaginal pH > 4.5 is a key finding.
- Wet mount may show a predominance of parabasal epithelial cells instead of the normal superficial cells.
- Differential Diagnostics (DDx)
- Infectious Vaginitis (e.g., Candidiasis, BV): Distinguished by specific discharge characteristics, microscopic findings (e.g., hyphae, clue cells), and normal vaginal pH in candidiasis. Itching is more prominent in candidiasis.
- Lichen Sclerosus: Presents with intense vulvar itching and characteristic “cigarette paper” skin changes or white plaques; typically spares the vagina.
- Contact Dermatitis: Caused by irritation from soaps, detergents, or panty liners; erythema and edema are usually more pronounced.
- Management (Tx)
- First-line (Mild Symptoms): Non-hormonal vaginal moisturizers (used regularly) and lubricants (used with intercourse).
- First-line (Moderate-to-Severe Symptoms): Low-dose topical estrogen preparations (creams, tablets, or rings) are the most effective treatment. These have minimal systemic absorption and are considered safe.
- Systemic HRT: Can be used if the patient also has other significant menopausal symptoms (e.g., vasomotor symptoms like hot flashes).