Atrophic vaginitis
🌸 Atrophic vaginitis, now more accurately termed Genitourinary Syndrome of Menopause (GSM), is a chronic, progressive condition caused by oestrogen deficiency, most commonly after the menopause.
Reduced oestrogen leads to thinning of the vaginal epithelium, loss of elasticity, reduced lubrication, and increased vaginal pH — resulting in vulvovaginal and urinary symptoms that can significantly affect quality of life.
Diagnosis is usually clinical and treatment is highly effective when appropriately targeted.
🩺 Clinical Features
- 🌸 Vaginal symptoms
- Dryness and soreness
- Itching or burning
- Dyspareunia (pain during intercourse)
- Post-coital spotting or discharge
- 🚻 Urinary symptoms
- Dysuria (often without infection)
- Urgency and frequency
- Recurrent UTIs
- Stress or urge urinary incontinence
- 🔍 Examination findings
- Thin, pale, smooth vaginal epithelium
- Loss of vaginal rugae and elasticity
- Narrowed vaginal canal and introital stenosis
- Fragile mucosa that may bleed on contact
- Elevated vaginal pH (usually >5)
🔎 Investigations
- Diagnosis is clinical — investigations are usually not required.
- 🧪 Urinalysis ± culture if urinary symptoms predominate, to exclude infection.
- 🧫 Vaginal pH testing (optional): pH >5 supports GSM.
- ⚠️ Unexplained vaginal bleeding warrants urgent investigation to exclude malignancy.
💊 Management Plan (Stepwise & Individualised)
- 🧴 First-line: Non-hormonal Therapy
- Regular use of vaginal moisturisers (2–3 times weekly).
- Lubricants during sexual activity.
- Emphasise routine use, not just pre-intercourse.
- 🌱 Topical Oestrogen Therapy (Gold Standard)
- Low-dose vaginal oestrogen (e.g. estriol cream, pessaries, or vaginal tablets).
- Restores vaginal epithelium, lowers pH, improves symptoms.
- Minimal systemic absorption — safe for most women.
- No progestogen required.
- Review at 3–6 months; treatment is often long-term.
- 🌡️ Systemic HRT
- Consider if GSM coexists with significant vasomotor symptoms (hot flushes, night sweats).
- Weigh benefits and risks individually.
- 📚 Patient Education & Lifestyle Advice
- Avoid irritants (perfumed soaps, douches).
- Encourage regular sexual activity (improves vaginal blood flow).
- Pelvic floor exercises for urinary symptoms.
- Reassure that GSM is common, treatable, and not an infection.
- 📨 Referral to Gynaecology
- Persistent symptoms despite adequate topical oestrogen.
- Diagnostic uncertainty.
- Recurrent or unexplained vaginal bleeding.
- History of oestrogen-dependent malignancy (specialist input).
- 🔁 Follow-up
- Review at 3–6 months to assess symptom control.
- Encourage prompt reporting of new bleeding, pain, or infection symptoms.
📚 Key Teaching Pearls
- 🧠 GSM is chronic and progressive without treatment.
- 🌱 Topical oestrogen is low risk and highly effective.
- 🚫 Antibiotics do not treat GSM — avoid repeated “UTI” misdiagnosis.
- 👩⚕️ Vaginal bleeding in postmenopausal women is cancer until proven otherwise.
- 🤝 Proactive questioning is essential — many women do not volunteer symptoms.
