Vaginal atrophy

Vaginal atrophy (atrophic vaginitis) is thinning, drying and inflammation of the vaginal walls that may occur when your body has less estrogen. Vaginal atrophy occurs most often after menopause.

For many women, vaginal atrophy not only makes intercourse painful but also leads to distressing urinary symptoms. Because the condition causes both vaginal and urinary symptoms, doctors use the term "genitourinary syndrome of menopause (GSM)" to describe vaginal atrophy and its accompanying symptoms.

Simple, effective treatments for GSM are available. Reduced estrogen levels result in changes to your body, but it doesn't mean you have to live with the discomfort of GSM.

Symptoms

Genitourinary syndrome of menopause (GSM) signs and symptoms may include:

• Vaginal dryness
• Vaginal burning
• Vaginal discharge
• Genital itching
• Burning with urination
• Urgency with urination
• Frequent urination
• Recurrent urinary tract infections
• Urinary incontinence
• Light bleeding after intercourse
• Discomfort with intercourse
• Decreased vaginal lubrication during sexual activity
• Shortening and tightening of the vaginal canal

When to see a doctor

Many postmenopausal women experience GSM. But few seek treatment. Women may be embarrassed to discuss their symptoms with their doctor and may resign themselves to living with these symptoms.

Make an appointment with your doctor if you have any unexplained vaginal spotting or bleeding, unusual discharge, burning, or soreness.

Also make an appointment to see your doctor if you experience painful intercourse that's not resolved by using a vaginal moisturizer (K-Y Liquibeads, Replens, Sliquid, others) or water-based lubricant (Astroglide, K-Y Jelly, Sliquid, others).

Causes

Genitourinary syndrome of menopause is caused by a decrease in estrogen production. Less estrogen makes your vaginal tissues thinner, drier, less elastic and more fragile.

A drop in estrogen levels may occur:

• After menopause
• During the years leading up to menopause (perimenopause)
• After surgical removal of both ovaries (surgical menopause)
• During breast-feeding
• While taking medications that can affect estrogen levels, such as some birth control pills
• After pelvic radiation therapy for cancer
• After chemotherapy for cancer
• As a side effect of breast cancer hormonal treatment

GSM signs and symptoms may begin to bother you during the years leading up to menopause, or they may not become a problem until several years into menopause. Although the condition is common, not all menopausal women experience GSM. Regular sexual activity, with or without a partner, can help you maintain healthy vaginal tissues.

Risk factors

Certain factors may contribute to GSM, such as:

• Smoking. Cigarette smoking affects your blood circulation, and may lessen the flow of blood and oxygen to the vagina and other nearby areas. Smoking also reduces the effects of naturally occurring estrogens in your body.
• No vaginal births. Researchers have observed that women who have never given birth vaginally are more likely to develop GSM symptoms than women who have had vaginal deliveries.
• No sexual activity. Sexual activity, with or without a partner, increases blood flow and makes your vaginal tissues more elastic.

Complications

Genitourinary syndrome of menopause increases your risk of:

• Vaginal infections. Changes in the acid balance of your vagina make vaginal infections more likely.
• Urinary problems. Urinary changes associated with GSM can contribute to urinary problems. You might experience increased frequency or urgency of urination or burning with urination. Some women experience more urinary tract infections or urine leakage (incontinence).

Prevention

Regular sexual activity, either with or without a partner, may help prevent genitourinary syndrome of menopause. Sexual activity increases blood flow to your vagina, which helps keep vaginal tissues healthy.

Diagnosis

Diagnosis of genitourinary syndrome of menopause (GSM) may involve:

• Pelvic exam, during which your doctor feels your pelvic organs and visually examines your external genitalia, vagina and cervix.
• Urine test, which involves collecting and testing your urine, if you have urinary symptoms.
• Acid balance test, which involves taking a sample of vaginal fluids or placing a paper indicator strip in your vagina to test its acid balance.

Treatment

To treat genitourinary syndrome of menopause, your doctor may first recommend over-the-counter treatment options, including:

• Vaginal moisturizers. Try a vaginal moisturizer (K-Y Liquibeads, Replens, Sliquid, others) to restore some moisture to your vaginal area. You may have to apply the moisturizer every few days. The effects of a moisturizer generally last a bit longer than those of a lubricant.
• Water-based lubricants. These lubricants (Astroglide, K-Y Jelly, Sliquid, others) are applied just before sexual activity and can reduce discomfort during intercourse. Choose products that don't contain glycerin or warming properties because women who are sensitive to these substances may experience irritation. Avoid petroleum jelly or other petroleum-based products for lubrication if you're also using condoms, because petroleum can break down latex condoms on contact.

If those options don't ease your symptoms, your doctor may recommend:

Topical estrogen

Vaginal estrogen has the advantage of being effective at lower doses and limiting your overall exposure to estrogen because less reaches your bloodstream. It may also provide better direct relief of symptoms than oral estrogen does.

Vaginal estrogen therapy comes in a number of forms. Because they all seem to work equally well, you and your doctor can decide which one is best for you.

• Vaginal estrogen cream (Estrace, Premarin). You insert this cream directly into your vagina with an applicator, usually at bedtime. Typically women use it daily for one to three weeks and then one to three times a week thereafter, but your doctor will let you know how much cream to use and how often to insert it.
• Vaginal estrogen suppositories (Imvexxy). These low-dose estrogen suppositories are inserted about 2 inches into the vaginal canal daily for weeks. Then, the suppositories only need to be inserted twice a week.
• Vaginal estrogen ring (Estring, Femring). You or your doctor inserts a soft, flexible ring into the upper part of the vagina. The ring releases a consistent dose of estrogen while in place and needs to be replaced about every three months. Many women like the convenience this offers. A different, higher dose ring is considered a systemic rather than topical treatment.
• Vaginal estrogen tablet (Vagifem). You use a disposable applicator to place a vaginal estrogen tablet in your vagina. Your doctor will let you know how often to insert the tablet. You might, for instance, use it daily for the first two weeks and then twice a week thereafter.

Ospemifene (Osphena)

Taken daily, this pill can help relieve painful sex symptoms in women with moderate to severe GSM. It is not approved in women who've had breast cancer or who have a high risk of developing breast cancer.

Prasterone (Intrarosa)

These vaginal inserts deliver the hormone DHEA directly to the vagina to help ease painful sex. DHEA is a hormone that helps the body produce other hormones, including estrogen. Prasterone is used nightly for moderate to severe vaginal atrophy.

Systemic estrogen therapy

If vaginal dryness is associated with other symptoms of menopause, such as moderate or severe hot flashes, your doctor may suggest estrogen pills, patches or gel, or a higher dose estrogen ring. Estrogen taken by mouth enters your entire system. Ask your doctor to explain the risks versus the benefits of oral estrogen, and whether or not you would also need to take another hormone called progestin along with estrogen.

Vaginal dilators

You may use vaginal dilators as a nonhormonal treatment option. Vaginal dilators may also be used in addition to estrogen therapy. These devices stimulate and stretch the vaginal muscles to reverse narrowing of the vagina.

If painful sex is a concern, vaginal dilators may relieve vaginal discomfort by stretching the vagina. They are available without a prescription, but if your symptoms are severe, your doctor may recommend pelvic floor physical therapy and vaginal dilators. Your health care provider or a pelvic physical therapist can teach you how to use vaginal dilators.

Topical lidocaine

Available as a prescription ointment or gel, topical lidocaine can be used to lessen discomfort associated with sexual activity. Apply it five to 10 minutes before you begin sexual activity.

If you've had breast cancer

If you have a history of breast cancer, tell your doctor and consider these options:

• Nonhormonal treatments. Try moisturizers and lubricants as a first choice.
• Vaginal dilators. Vaginal dilators are a nonhormonal option that can stimulate and stretch the vaginal muscles. This helps to reverse narrowing of the vagina.
• Vaginal estrogen. In consultation with your cancer specialist (oncologist), your doctor might recommend low-dose vaginal estrogen if nonhormonal treatments don't help your symptoms. However, there's some concern that vaginal estrogen might increase your risk of the cancer coming back, especially if your breast cancer was hormonally sensitive.
• Systemic estrogen therapy. Systemic estrogen treatment generally isn't recommended, especially if your breast cancer was hormonally sensitive.

Lifestyle and home remedies

If you're experiencing vaginal dryness or irritation, you may find relief if you:

• Try an over-the-counter moisturizer. Examples include K-Y Liquibeads, Replens and Sliquid. This can restore some moisture to your vaginal area.
• Use an over-the-counter water-based lubricant. A lubricant can reduce discomfort during intercourse. Examples include Astroglide, K-Y Jelly and Sliquid.
• Allow time to become aroused during intercourse. The vaginal lubrication that results from sexual arousal can help reduce symptoms of dryness or burning.

Alternative medicine

Some alternative medicines are used to treat vaginal dryness and irritation associated with menopause, but few approaches are backed by sufficient evidence from clinical trials. Interest in complementary and alternative medicine is growing, and researchers are working to determine the benefits and risks of various alternative treatments for genitourinary syndrome of menopause.

Talk with your doctor before taking any herbal or dietary supplements for perimenopausal or menopausal symptoms. The Food and Drug Administration doesn't regulate herbal products, and some may interact with other medications you take, putting your health at risk.

Preparing for an appointment

You'll probably start by discussing your symptoms with your primary care provider. If you aren't already seeing a doctor who specializes in women's health (gynecologist or internal medicine women's health specialist), your primary care provider may refer you to one.

What you can do

To prepare for your appointment:

• Make a list of any signs and symptoms you're experiencing. Include those that may seem unrelated to the reason for your appointment.
• Make a note of key personal information. Include any major stresses or recent life changes.
• Make a list of all medications that you take. Include prescription and nonprescription drugs, vitamins and supplements and note the doses.
• Consider taking a family member or friend along. Sometimes it can be difficult to remember all the information provided during an appointment. Someone who goes with you may remember something that you missed or forgot.
• Prepare questions. Make the most of your time with your doctor by preparing a list of questions before your appointment.

Some basic questions to ask include:

• What's the most likely cause of my symptoms?
• Are there other possible causes?
• What kinds of tests do I need?
• Is my condition likely temporary or long lasting?
• What treatment options are available? What do you recommend for me?
• What are the alternatives to the primary approach that you're suggesting?
• I have some other health conditions. How can I best manage these conditions together?
• Should I see a specialist?
• Are there brochures or other printed materials that I can have? What websites do you recommend?

What to expect from your doctor

Your doctor will ask questions about your symptoms and assess your hormonal status. Questions your doctor may ask include:

• What vaginal or urinary symptoms have you noticed?
• How long have you had these symptoms?
• Are you still having menstrual periods?
• How much distress do your symptoms cause you?
• Are you sexually active?
• Do your symptoms limit your sexual activity?
• Have you been treated for cancer?
• Do you use scented soap or bubble bath?
• Do you douche or use feminine hygiene spray?
• What medications, vitamins or other supplements do you take?
• Have you tried any over-the-counter moisturizers or lubricants?

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