Atrophic vaginitis

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Overview
Atrophic vaginitis (also known as vaginal atrophy or urogenital atrophy) is an inflammation of the vagina (and the outer urinary tract) due to the thinning and shrinking of the tissues, as well as decreased lubrication. This is all due to a lack of the reproductive hormone estrogen.

The most common cause of vaginal atrophy is the decrease in estrogen which happens naturally during perimenopause, and increasingly so in post-menopause. However this condition can sometimes be caused by other circumstances.

The symptoms include vaginal soreness and itching, as well as painful intercourse, and bleeding after sexual intercourse. The shrinkage of the tissues can be extreme enough to make intercourse impossible.

Symptoms and signs
Genital symptoms include dryness, itching, burning, soreness, pressure, thick yellow white discharge, malodorous discharge, infection, painful sexual intercourse, bleeding after intercourse. In addition, sores and cracks may occur.

Urinary symptoms include painful urination, blood in the urine, increased frequency of urination, incontinence, and increased likelihood and occurrence of infections.

Incidence and causes
A large number of postmenopausal women (who are not using topical estrogen) have at least some degree of vaginal atrophy, however, many women do not actively ask that medical attention be paid to this, possibly because it is naturally caused, or because of the taboo that still exists surrounding aging and sexuality.

The cause of vaginal atrophy is usually the normal decrease in estrogen as a result of menopause. Other causes of decreased estrogen are decreased ovarian functioning due to radiation therapy or chemotherapy, immune disorder, removal of the ovaries, after pregnancy, during lactation, idiopathic, and because of the effects of various medications (Tamoxifen (Nolvadex), Danazol (Danocrine), Medroxyprogesterone (Provera), Leuprolide (Lupron), Nafarelin (Synarel)).

Treatment
Topical estrogen creams or tablets may be used vaginally. Oral or transdermal estrogen may be used. See Boxed Warning about estrogen therapy below.

Sexual activity is also helpful. A water-soluble vaginal lubricant may be useful.

Boxed Warning
The labeling of estrogen-only products includes a boxed warning that unopposed estrogen (without progestin) therapy increases the risk of endometrial cancer. Based on a review of data from the WHI, on January 8 2003 the FDA changed the labeling of all estrogen and estrogen with progestin products for use by postmenopausal women to include a new boxed warning about cardiovascular and other risks. The estrogen-alone sub-study of the WHI reported an increased risk of stroke and deep vein thrombosis (DVT) in postmenopausal women 50 years of age or older and an increased risk of dementia in postmenopausal women 65 years of age or older using 0.625 mg of Premarin conjugated equine estrogens (CEE). The estrogen-plus-progestin substudy of the WHI reported an increased risk of myocardial infarction, stroke, invasive breast cancer, pulmonary emboli and DVT in postmenopausal women 50 years of age or older and an increased risk of dementia in postmenopausal women 65 years of age or older using 0.625 mg of CEE with 2.5 mg of the progestin medroxyprogesterone acetate (MPA).

Prognosis
Proper treatment will usually relieve the symptoms, at least to some extent.

Prevention
Use of vaginal estrogen before the condition becomes severe is appropriate. Regular sexual activity may be helpful. A water soluble vaginal lubricant can be helpful in mild cases.