Lactational Atrophic Vaginitis

Amy R. Palmer, CNM, MSN, Frances E. Likis, CNM, MSN, FNP

Disclosures

J Midwifery Womens Health. 2003;48(4) 

In This Article

Discussion

In the postpartum period, estrogen levels decline secondary to the loss of placental estrogen. Women who breastfeed have high levels of prolactin that exert an antagonistic action on estrogen production.[1] For these reasons, hypoestrogenemia can occur throughout lactation.[2] Decreased estrogen levels can cause urogenital atrophy, including epithelial thinning, decreased elasticity, and diminished vaginal blood flow.[3] Symptomatic hypoestrogenic vulvovaginal changes are often referred to as atrophic vaginitis and typically present as vaginal dryness, itching, burning, irritation, and dyspareunia. Hypoestrogenemia may also cause urinary symptoms such as dysuria, urgency, and frequency.[1,3] Because women may not self-report such symptoms, it is important to ask about postpartum vaginal and sexual health.

A MEDLINE search of journal citations since 1966 was performed by using the keywords atrophic vaginitis, breastfeeding, lactation, postpartum, and vaginal atrophy. Results included only 3 relevant articles.[4,5,6] Further research is needed to determine the prevalence of lactational atrophic vaginitis, as well as optimal treatments. For now, diagnosis and treatment of lactational atrophic vaginitis primarily relies on the literature related to this condition during menopause.

Examination is crucial in the diagnosis of vulvovaginal atrophy. Shrinking and dryness of the labia may be noted, as well as inflammation and erythema of the vulva. The walls of the vagina may appear pale with poor rugation, and patches of inflammation may be present. Petechiae and ecchymosis may also be noted, and vaginal and cervical secretions are typically decreased. Friability can occur due to the fragility of the vaginal mucosa. In addition, inserting the fingers or speculum for examination may be difficult and painful due to stenosis of the introitus and vaginal dryness.[1,3]

Useful laboratory tests include pH measurement and wet preparations for microscopy. Decreased estrogen levels cause the vaginal pH to become more alkaline, typically with levels greater than 5.0. Microscopic examination of the vaginal secretions often reveals decreased lactobacilli, and can also be used to rule out other causes of vaginitis (e.g., bacterial vaginosis, candidiasis, and trichomoniasis).[1] If the diagnosis is still uncertain after the history, physical examination, and testing described, a smear from the upper third of the vaginal wall can be sent for cytologic examination. Typically, there will be decreased superficial cells and increased basal and parabasal cells with atrophic vaginitis.[3]

The management of atrophic vaginitis may include self-help measures, estrogen replacement, and botanical therapies, as well as education. Self-help measures include the use of water-based vaginal lubricants or vaginal moisturizers, which are available without prescription. Vitamin E oil can also be used for lubrication and to relieve symptoms of pruritus and irritation.[3]

Because atrophic vaginitis results from decreased estrogen, replacement of this hormone can often be helpful. Small amounts of topical estrogen applied over a few weeks to the vaginal and vulvar tissues typically result in a dramatic response, with thickening, lubrication, and return of elasticity to the tissues. This usually results in pain-free vaginal penetration, greatly enhancing the woman's sexual pleasure. Vaginal estrogen preparations available for the treatment of atrophic vaginitis include creams containing conjugated equine estrogens or 17 -estradiol, estradiol hemihydrate tablets, and a 17 -estradiol ring. Studies of the use of these products by menopausal women demonstrate they are all efficacious for the treatment of vaginal atrophy. Systemic absorption is lower with the use of vaginal tablets or rings when compared with cream.[7] The dosing of tablets and creams can be individualized by the severity of symptoms and relief provided, and these preparations can be used in conjunction with vaginal lubricants and moisturizers. Because topical estrogen products contain unopposed estrogen, there is the possibility that they could cause endometrial proliferation, hyperplasia, or carcinoma.[3] Data are limited regarding the endometrial safety of vaginal estrogen, but it is prudent to use the minimum dose needed and to consider the need for endometrial assessment in any woman using these products who reports abnormal bleeding. Women using barrier methods for contraception should be cautioned that the components of some creams might weaken latex condoms, diaphragms, or cervical caps, resulting in contraceptive failure.

Another option for replacing estrogen in the woman who simultaneously needs contraception is the use of combined contraceptives containing estrogen: combined oral contraceptives (COCs), the combined injectable contraceptive (CIC), the combined contraceptive vaginal ring, or the combination transdermal contraceptive patch. The World Health Organization criteria for contraceptive use indicate that the advantages of COCs and CIC generally outweigh the theoretical or proven risks for breastfeeding women who are 6 months or more postpartum.[8] Recommendations regarding the combined contraceptive ring and patch are not yet available but are presumed to be the same as their prototype, COCs.

Botanical therapies that are used in the management of hypoestrogenic vulvovaginal symptoms include phytoestrogens (found in soy products), black cohosh, dong quai, and ginseng, although evidence of their efficacy has not been conclusive.[3]

Women with hypoestrogenic urogenital symptoms associated with long-term lactation should be informed of the etiology of the condition and treatment options. In particular, it is important to reassure women that the symptoms should resolve with the cessation of lactation when estrogen levels return to normal (often noted through return of menstrual cycles). As with all sexual concerns, communication is key to enhanced relationship support, and the woman may need encouragement to communicate her needs and concerns to her partner.

When estrogen is prescribed to a breastfeeding woman, it is important that she be educated about the potential effects of estrogen replacement on fertility and milk supply. As estrogen is reintroduced in the body, fertility may resume (unless combined contraceptives are used) and prolactin levels may decrease, resulting in diminished milk production.[2]

Lactational atrophic vaginitis can be a distressing problem to nursing mothers and is probably underrecognized by clinicians. For women's health practitioners to properly care for those suffering from this problem, they must realize that it exists and be familiar with treatment options. Hopefully, after more cases are seen and shared and new research is conducted, practitioners will recognize lactational atrophic vaginitis and be able to empower women with this condition to make the best treatment decisions for themselves and their families.

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