Vaginal atrophy is the drying, thinning, and inflammation of the vaginal walls that may occur secondary to permanently diminished levels of estrogen in the body after menopause. In the setting of menopause, the vagina is not alone: there are substantial regressive changes in the appearance of all of a woman’s reproductive organs because of lower estrogen, which normally functions as a major growth factor of the female reproductive tract. It is estimated that up to 45% of postmenopausal women experience atrophy of the vaginal lining.
As the vagina undergoes atrophy, the anatomical wrinkles (rugae) of the vaginal walls progressively flatten as they lose collagen, fatty tissue, and their ability to retain water. These changes result in a thinner vaginal lining. If the vaginal atrophy becomes symptomatic, it is then known as atrophic vaginitis (characterized by vaginal dryness, itching, irritation, and painful intercourse). The thinner vaginal lining becomes less elastic, more easily traumatized, and more prone to bleeding with minimal trauma. As the vaginal atrophy progresses, the vaginal opening and canal progressively narrow.
In addition to vaginal changes, atrophic changes develop in the vulva. Secretions from vulvar sebaceous glands diminish. The fatty tissue in the vulvar labia is lost, which leads to shrinkage, fusion, and narrowing of the vaginal opening.
For many women, symptomatic vaginal atrophy (also known as atrophic vaginitis) causes a recurring distressing vaginal discharge that is thin, watery, yellow or gray in color. It also causes itching, discomfort or pain during intercourse, decreased lubrication during sexual activity (usually the first sign of atrophic vaginitis), light bleeding post-intercourse, and when severe, a sense of vaginal shortening and narrowing. Symptomatic vaginal atrophy is also associated with urinary symptoms such as burning and urgency with urination, more frequent urinary tract infections, and urinary incontinence.
On examination, the vagina and vulva are pale, thin-appearing, and less elastic. As mentioned, in a more advanced state the vaginal opening and canal become narrower. There may be minor cuts near the vaginal opening because of the lack of elasticity. The bladder may be seen sagging into the vagina. The cervix is usually smaller and pale, and it produces less mucus, which adds to the vaginal dryness.
Simple effective local treatments for the symptoms of vaginal atrophy are available. These are preferable to oral treatment as they have fewer systemic effects on the breast and cardiovascular system. Initial treatments for mild symptoms include vaginal moisturizers, such as K-Y Liquibeads, Replens, Sliquid, Hyalofemme, and Silk-E, which add moisture and may loosen the vagina.
For women seeking relief from painful sex, water-based lubricants, such as K-Y Jelly, Astroglide, can be used to improve comfort during intercourse. Many women use olive oil or coconut oils as a natural moisturizer and lubricant, but occasionally these may cause an allergic irritation. There is a newly approved vaginal insert, however, that consists of estrogen embedded within a coconut oil vehicle (Imvexxy).
Importantly, neither moisturizers nor lubricants will completely restore the health of the vagina. For women who fail to gain relief from moisturizers and lubricants and who may by now have moderate to severe symptoms, applying topical estrogen (in the form of a cream, vaginal pill/suppository, or a ring) inside the vagina helps thicken the vaginal tissues and restore the normal acid balance of the vagina. This increases vaginal moisture and sensitivity.
Finally, for women in whom hormonal therapy is not an option or is ineffective, fractionated CO2 laser therapy, such as with the MonaLisa TouchR System, in the office has been shown to significantly improve the symptoms of vaginal atrophy by stimulating the vagina’s connective tissue to produce new collagen. This promotes improved blood flow and tissue regeneration for vaginal lubrication and elasticity.
Regular sexual activity, either with or without a partner, can help prevent the symptoms of vaginal atrophy Sexual activity increases blood flow to the vagina, which helps keep vaginal tissues healthy. Refraining from smoking is also preventive. Ways to keep vaginal atrophy from worsening include avoiding perfumes, powders, deodorants in the vaginal area and tight-fitting clothing and panty liners.
We at Adaptive Gynecology work closely with women experiencing the quality of life frustrations posed by symptomatic vaginal atrophy and help them gain much-needed relief.
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