Atrophic Vaginitis (Genitourinary Syndrome of Menopause)
Summary
Atrophic vaginitis, now termed Genitourinary Syndrome of Menopause (GSM), is a common condition caused by declining oestrogen levels after menopause. It leads to thinning, drying, and inflammation of the vaginal walls, causing symptoms of vaginal dryness, dyspareunia (painful sex), itching, and urinary symptoms (urgency, frequency, recurrent UTIs). Unlike vasomotor symptoms, GSM does not improve with time and often worsens without treatment. First-line treatment is vaginal oestrogen, which is highly effective, has minimal systemic absorption, and is safe for most women including those with breast cancer history (with specialist advice).
Key Facts
- Cause: Oestrogen deficiency (menopause)
- Prevalence: 40-60% of postmenopausal women
- Symptoms: Vaginal dryness, Dyspareunia, Itching, Urinary urgency, Recurrent UTIs
- Signs: Pale, thin, dry mucosa; Loss of rugae; Raised pH (>4.5)
- Treatment: Vaginal oestrogen (very low systemic absorption)
- Key Point: Does NOT improve with time — treatment needed
Clinical Pearls
"GSM Doesn't Burn Out": Unlike hot flushes, vaginal atrophy gets worse with time if untreated.
"Vaginal pH >4.5": Loss of oestrogen → Loss of glycogen → Loss of Lactobacilli → Raised vaginal pH (>4.5).
"Local Oestrogen is Safe": Vaginal oestrogen has minimal systemic absorption and is safe for most women, including many with breast cancer history (discuss with oncologist).
"Ask the Question": Many women don't mention symptoms due to embarrassment. Ask specifically about vaginal dryness and sexual discomfort.
Prevalence
- 40-60% of postmenopausal women
- Increases with years since menopause
- Often underreported
Risk Factors
| Factor | Notes |
|---|---|
| Menopause | Primary cause |
| Surgical oophorectomy | Earlier onset |
| Breastfeeding | Temporary oestrogen deficiency |
| Chemotherapy/Radiotherapy | Induced menopause |
| Aromatase inhibitors | Profound oestrogen suppression |
| Smoking | Reduces oestrogen levels |
Mechanism
- Oestrogen falls (menopause)
- Vaginal epithelium thins (fewer cell layers)
- Reduced blood flow to vagina and vulva
- Decreased lubrication
- Loss of glycogen → Reduced Lactobacilli → Raised pH (>4.5)
- Increased susceptibility to infection
Urogenital Effects
- Vaginal: Dryness, thinning, fragility
- Urethral: Thinning, reduced mucosal coaptation → UTI, urgency
- Pelvic floor: Weakening
Vaginal Symptoms
| Symptom | Description |
|---|---|
| Dryness | Most common symptom |
| Dyspareunia | Superficial pain during intercourse |
| Itching | Vulvovaginal irritation |
| Discharge | May be watery or yellow |
| Bleeding | Postcoital or spontaneous (fragile mucosa) |
Urinary Symptoms
| Symptom | Description |
|---|---|
| Recurrent UTIs | Due to pH changes and mucosal fragility |
| Urgency/Frequency | Urethral irritation |
| Dysuria | Without infection |
| Stress incontinence | Pelvic floor and urethral changes |
Speculum Examination
- Pale, dry, thin vaginal mucosa
- Loss of rugae (smooth walls)
- Petechiae (fragile)
- May see erythema, erosions
- Narrowing of introitus (may be difficult to pass speculum)
Vulval Examination
- Thinning of labia majora
- Narrowing of introitus
- Fusion of labia minora (advanced)
Usually Clinical Diagnosis
- No investigations required for typical presentation
If Postmenopausal Bleeding
- Transvaginal ultrasound (endometrial thickness)
- Endometrial biopsy (if thickness >4mm or suspicious)
- Rule out endometrial cancer
Other
- Vaginal pH: >4.5 supports diagnosis
- Urine MSU: If recurrent UTI
Treatment Approach
┌──────────────────────────────────────────────────────────┐
│ GSM / ATROPHIC VAGINITIS MANAGEMENT │
├──────────────────────────────────────────────────────────┤
│ │
│ NON-HORMONAL OPTIONS (First-line if preferred): │
│ • Vaginal moisturisers (Replens, Yes VM) — 2-3x/week │
│ • Lubricants during intercourse (Sylk, Yes) │
│ • Adequate hydration │
│ • Regular sexual activity (maintains blood flow) │
│ │
│ VAGINAL OESTROGEN (FIRST-LINE FOR MOST): │
│ • Highly effective, minimal systemic absorption │
│ • Options: │
│ - Oestradiol pessary (Vagifem 10mcg) — 2 weeks daily │
│ then 2x/week │
│ - Oestriol cream (Ovestin) — 2 weeks daily then │
│ 2x/week │
│ - Oestradiol ring (Estring) — 3-monthly │
│ • Can use long-term; no routine endometrial monitoring │
│ • Safe for most women (discuss with oncologist if │
│ breast cancer history) │
│ │
│ SYSTEMIC HRT: │
│ • If also has vasomotor symptoms │
│ • May need additional vaginal oestrogen │
│ │
│ OTHER: │
│ • Ospemifene (oral SERM) — alternative if vaginal │
│ oestrogen declined │
│ • Laser therapy (emerging; not widely available) │
│ │
│ RECURRENT UTIs: │
│ • Vaginal oestrogen reduces recurrence │
│ • +/- low-dose prophylactic antibiotic │
│ │
└──────────────────────────────────────────────────────────┘
Of GSM
- Recurrent UTIs
- Dyspareunia → Sexual dysfunction → Relationship issues
- Vaginal bleeding (fragility)
- Reduced quality of life
Of Treatment
- Vaginal oestrogen: Generally very safe
- Rare: Breast tenderness, vaginal bleeding (resolve or investigate)
Without Treatment
- Symptoms persist and worsen over time
- Does NOT improve spontaneously
With Treatment
- Symptoms improve within 2-4 weeks
- Long-term treatment usually needed
Key Guidelines
- BMS: Management of Genitourinary Symptoms in Postmenopausal Women
- NICE NG23: Menopause
Key Evidence
Vaginal Oestrogen
- Highly effective (RCT evidence)
- Minimal systemic absorption
- No increased endometrial cancer risk
What is Atrophic Vaginitis?
Atrophic vaginitis (also called "Genitourinary Syndrome of Menopause" or GSM) is when the vagina becomes dry, thin, and inflamed due to low oestrogen levels after menopause.
What Are the Symptoms?
- Vaginal dryness and discomfort
- Pain during sex
- Itching or burning
- Needing to wee more often or urgently
- Repeated urine infections
Does It Get Better on Its Own?
No. Unlike hot flushes, vaginal dryness often gets worse without treatment.
How is It Treated?
- Moisturisers and lubricants: For mild symptoms
- Vaginal oestrogen: Small tablets, creams, or rings put into the vagina. Very effective and safe for most women.
- These can be used long-term if needed
Is Vaginal Oestrogen Safe?
Yes. Very little is absorbed into the body. It's safe for most women, including many with a history of breast cancer (your doctor can advise).
Don't Be Embarrassed
This is a very common problem. If you're struggling, please speak to your doctor — effective treatments are available.
Primary Guidelines
- British Menopause Society. Management of Genitourinary Symptoms in Postmenopausal Women. 2022.
- NICE. Menopause: Diagnosis and Management (NG23). 2015, updated 2019.
Key Studies
- Suckling J, et al. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2006. PMID: 17054169