Lactational Atrophic Vaginitis

Abstract and Case Description

Atrophic vaginitis is typically associated with the hypoestrogenic state of menopause. However, lactation also decreases estrogen levels and can cause symptomatic urogenital atrophy. Discussion of this clinical phenomenon in the literature is minimal. A case report of atrophic vaginitis at 13 months postpartum is presented. Mechanisms of action, evaluation, and treatments for lactational atrophic vaginitis are reviewed with recommendations for further research on this topic.

A 28-year-old primipara woman presented to the birth center at 13 months postpartum. She reported discomfort with urination, vaginal itching and dryness, and severe pain during intercourse described as "someone ripping out her insides." She had intercourse only four times since giving birth and experienced significant pain each time. She tried lubricants to relieve her symptoms, as well as increased foreplay to improve arousal and vaginal secretions. These measures provided only minimal relief. She has been breastfeeding her daughter since birth and remains amenorrheic. Her pregnancy and birth were uncomplicated, and she has an unremarkable medical history. A discussion about her relationship revealed a strong love for her husband and concerns that her inability to be intimate with him was ruining their marriage.

On external genital examination, her vulva was pale pink, shiny, and inflamed with small areas of erythema and petechiae present. Her vaginal tone was strong; in fact, the muscles were so tight that she found it difficult to relax them and was uncomfortable with the speculum examination. Her cervix and vaginal walls had the same appearance as the outer genitalia, and there was very little vaginal discharge noted. A saline and potassium hydroxide (KOH) wet preparation was performed with the findings of white and red blood cells, very few lactobacilli, and no clue cells or hyphae. Thus, there was no evidence of infection.

Based on her history and examination, a diagnosis of atrophic vaginitis related to lactation was made. Because previous self-help measures had been unsuccessful, she was offered vaginal estrogen cream. She was conflicted between the desire to resolve her symptoms and concern about the effect of estrogen on milk production, but she elected to use the cream after thorough counseling and careful consideration of her options. After 2 weeks of using 17 -estradiol cream two to three times a week, she was feeling better and the symptoms were subsiding. She called the birth center to report that the treatment was working, she was still nursing with no decrease in milk supply, and intercourse was much more enjoyable.

J Midwifery Womens Health. 2003;48(4) © 2003 Elsevier Science, Inc.