Author: Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand. Reviewed by Dr Jennifer Bradford, Gynaecologist, Sydney, Australia. Updated by Dr Oakley, February 2014.
Atrophic vulvovaginitis means thinned genital tissues in women. Often it is shortened to atrophic vaginitis, as it is vaginal tissue that is most often symptomatic.
Atrophic vulvovaginitis is associated with oestrogen deficiency due to:
Deficiency of oestrogen may also lead to dysuria (burning sensation when passing urine), urinary urgency, frequency and incontinence (the genitourinary syndrome of menopause).
Lack of oestrogen causes changes in the normal vaginal organisms. Those seen in younger women (especially lactobacilli) disappear and are replaced by gram negative organisms such as Escherichia coli or those associated with bacterial vaginosis. Urinary or bladder infections are more common in postmenopausal women than in younger women.
Atrophic vulvovaginitis changes the appearance of the female genitalia:
Tests may be performed in atrophic vulvovaginitis if any symptoms are present. These may include:
The following measures are recommended.
Atrophic vulvovaginitis is treated with topical oestrogen, a prescription medicine. This can be provided as vaginal cream, pessaries or vaginal ring. In New Zealand, Ovestin™, which contains oestriol, is used in a dose of 0.5 mg/day for 1–2 weeks then once or twice weekly. It can be inserted with an applicator or on a fingertip. Vagifem™ pessaries (containing oestrodiol) can also be used but are not currently funded by PHARMAC in New Zealand.
Oestrogen treatment results in:
Topical oestrogen is considered safe because very little is absorbed systemically. However, it is not usually prescribed to women with severe liver disease, oestrogen-dependent cancers or thromboembolic disease in case it increases the risk of these conditions.
Other forms of oestrogen are sometimes recommended including tablets, transdermal patches, gels, sprays and emulsions. Systemic oestrogen is usually mixed with progestogens. There are important risks and side effects so they are not usually used if atrophic vaginitis is the only problem.
Topical oestrogen may cause side effects, including:
When used just once or twice weekly, other side effects described with higher doses or modes of delivery of oestrogen do not arise.
Experimental options for vulvovaginal rejuvenation in symptomatic women that are unsuitable for or intolerant of local or systemic oestrogen therapy include:
Optimum regimens, effectiveness and safety of these procedures are as yet undetermined.
Arroyo C. Fractional CO(2) laser treatment for vulvovaginal atrophy symptoms and vaginal rejuvenation in perimenopausal women. Int J Womens Health. 2017 Aug 28;9:591-595. doi: 10.2147/IJWH.S136857. eCollection 2017. PubMed PMID: 28894392; PubMed Central PMCID: PMC5584900. Journal.
Vulvovaginal Disorders: an algorithm for basic adult diagnosis and treatment — ISSVD
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