COMMENTARY

Treating Atrophic Vaginitis

Laurie Scudder, DNP, NP

Disclosures

July 21, 2011

Atrophic Vaginitis

Pearson T
The Journal for Nurse Practitioners. 2011;7:502-505

Study Summary

Background. Atrophic vaginitis (AV), the result of estrogen deficiency, is experienced by almost half of postmenopausal women. AV contributes to a host of symptoms including itching, burning, dryness, and irritation, all of which can lead to dyspareunia. A decline in estrogen alters the vaginal flora, which permits bacterial overgrowth, sometimes accompanied by vaginal discharge. Declining estrogen also affects the urinary tract, leading to thinning of the bladder and urethral linings and potentially resulting in chronic dysuria and an increased incidence of urinary tract infections. The sensitivity of a discussion about painful intercourse may inhibit many women from mentioning this concern or seeking treatment.

Diagnosis. The diagnosis of AV is primarily clinical and begins with the ascertainment of specific symptoms: vaginal dryness, burning, pruritis, abnormal discharge, and dyspareunia. These symptoms may be more prominent in women who are younger at the time of menopause, who are non-white, who have diabetes, and who have a lower body mass index. Additionally, symptoms have been found to be more severe in women who have not experienced a vaginal delivery. On examination, providers will note atrophy of the labia major and minora with loss of subcutaneous fat. Along with dry labia, vulvar lesions and sparse pubic hair are common. The vaginal epithelium may appear pale, smooth, dry, and friable, with a loss of rugae. Areas of inflammation with patchy erythema and petechiae may be noted. A test of vaginal pH, using simple litmus paper held against the vaginal wall until moist, can help to clarify the diagnosis. A pH level > 5.0 is indicative of AV.

Management. Treatment begins with vaginal moisturizers and lubricants, a variety of which are available over the counter. When these are not effective, vaginal or systemic estrogen therapy, either alone or combined with progesterone, should be initiated at the lowest effective dose for the shortest duration needed. Both routes are effective, although the safety of systemic hormone therapy continues to be a concern, particularly in some subgroups of women. Estrogen-only vaginal products are available as creams, which tend to cost less, or vaginal tablets, which are less messy. Either should be used daily for 2 weeks to induce a therapeutic response and then continued as maintenance 2-3 times per week. Vaginal estrogen rings offer convenience because they need only be inserted every 90 days.

Viewpoint

The article provides a comprehensive, evidence-based review of the treatment of this all-too-common condition. Its most important contribution, however, may be the reminder to all who care for postmenopausal women of the dramatic incidence of this condition and the need to be proactive in querying women about telltale symptoms. The potential to improve the quality of life for this large group of women is significant.

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