Vaginal atrophy, also called atrophic vaginitis, is thinning, drying and inflammation of the vaginal walls due to your body having less estrogen. Vaginal atrophy occurs most often after menopause, but it can also develop during breast-feeding or at any other time your body's estrogen production declines.
For many women, vaginal atrophy makes intercourse painful — and if intercourse hurts, your interest in sex will naturally decrease. In addition, healthy genital function is closely connected with healthy urinary system function.
Simple, effective treatments for vaginal atrophy are available. Reduced estrogen levels result in changes to your body, but it doesn't mean you have to live with the discomfort of vaginal atrophy.
With moderate to severe vaginal atrophy, you may experience the following vaginal and urinary signs and symptoms:
- Vaginal dryness
- Vaginal burning
- Vaginal discharge
- Genital itching
- Burning with urination
- Urgency with urination
- More urinary tract infections
- Urinary incontinence
- Light bleeding after intercourse
- Discomfort with intercourse
- Decreased vaginal lubrication during sexual activity
- Shortening and tightening of the vaginal canal
When to see a doctor
By some estimates, nearly half of postmenopausal women experience vaginal atrophy, although few seek treatment. Many women resign themselves to the symptoms or are embarrassed to discuss them with their doctor.
Make an appointment to see your doctor if you experience painful intercourse that's not resolved by using a vaginal moisturizer (Replens, Vagisil Feminine Moisturizer, others) or water-based lubricant (glycerin-free versions of Astroglide, K-Y Intrigue, others) or if you have vaginal symptoms, such as unusual bleeding, discharge, burning or soreness.
Vaginal atrophy is caused by a decrease in estrogen production. Less estrogen makes your vaginal tissues thinner, drier, less elastic and more fragile.
A drop in estrogen levels and vaginal atrophy may occur:
- After menopause
- During the years leading up to menopause (perimenopause)
- During breast-feeding
- After surgical removal of both ovaries (surgical menopause)
- After pelvic radiation therapy for cancer
- After chemotherapy for cancer
- As a side effect of breast cancer hormonal treatment
Vaginal atrophy due to menopause may begin to bother you during the years leading up to menopause, or it may not become a problem until several years into menopause. Although the condition is common, not all menopausal women develop vaginal atrophy. Regular sexual activity, with or without a partner, can help you maintain healthy vaginal tissues.
Certain factors may contribute to vaginal atrophy, such as:
- Smoking. Cigarette smoking affects your blood circulation, resulting in the vagina and other tissues not getting enough oxygen. Smoking also reduces the effects of naturally occurring estrogens in your body. In addition, women who smoke typically experience an earlier menopause.
- No vaginal births. Researchers have observed that women who have never given birth vaginally are more likely to develop vaginal atrophy than women who have had vaginal deliveries.
- No sexual activity. Sexual activity, with or without a partner, increases blood flow and makes your tissues more elastic.
Vaginal atrophy increases your risk of vaginal infections and urinary problems.
- Vaginal infections. Vaginal atrophy leads to a change in the acid balance of your vagina, making you more likely to get a vaginal infection (vaginitis).
- Urinary problems. Atrophic vaginal changes are associated with changes in your urinary system (genitourinary atrophy), which can contribute to urinary problems. You might experience increased frequency or urgency of urination or burning with urination. Some women experience more urinary tract infections or incontinence.
You'll probably start by discussing your symptoms with your primary care provider. If you aren't already seeing a doctor who specializes in women's health (gynecologist or internal medicine women's health specialist), your primary care provider may refer you to one.
What you can do
To prepare for your appointment:
- Make a list of any signs and symptoms you're experiencing. Include those that may seem unrelated to the reason for your appointment.
- Make a note of key personal information. Include any major stresses or recent life changes.
- Make a list of all medications and the doses. Include prescription and non-prescription drugs, vitamins and supplements that you're taking.
- Consider taking a family member or friend along. Sometimes it can be difficult to remember all the information provided during an appointment. Someone who goes with you may remember something that you missed or forgot.
- Prepare questions. Your time with your doctor is limited, so preparing a list of questions can help you make the most of your time together.
Some basic questions to ask include:
- What is likely causing my symptoms or condition?
- What are other possible causes for my symptoms or condition?
- What kinds of tests do I need?
- Is my condition likely temporary or chronic?
- What is the best course of action?
- What are the alternatives to the primary approach that you're suggesting?
- I have some other health conditions. How can I best manage them together?
- Are there any restrictions that I need to follow?
- Should I see a specialist?
- Are there brochures or other printed materials that I can have? What websites do you recommend?
Questions your doctor may ask
Your doctor will ask questions about your symptoms and assess your hormonal status. Questions your doctor may ask include:
- What vaginal symptoms are you experiencing?
- How long have you experienced these symptoms?
- Do you continue to have menstrual periods?
- How much distress do your symptoms cause you?
- Are you sexually active?
- Does the condition limit your sexual activity?
- Have you been treated for cancer?
- Do you use scented soap or bubble bath?
- Do you douche or use feminine hygiene spray?
- What medications, vitamins or other supplements do you take?
- Have you tried any over-the-counter moisturizers or lubricants?
Diagnosis of vaginal atrophy may involve:
- Pelvic exam, during which your doctor feels (palpates) your pelvic organs and visually examines your external genitalia, vagina and cervix. During the pelvic exam, your doctor also checks for signs of pelvic organ prolapse — indicated by bulges in your vaginal walls from pelvic organs such as your bladder or rectum or stretching of the support tissues of the uterus.
- Urine test, which involves collecting and analyzing your urine, if you have urinary symptoms.
- Acid balance test, which involves taking a sample of vaginal fluids or placing a paper indicator strip in your vagina to test its acid balance.
Your doctor may first recommend that you:
- Try a vaginal moisturizer (Replens, Vagisil Feminine Moisturizer, others) to restore some moisture to your vaginal area. You may have to apply the moisturizer every two to three days. The effects of a moisturizer generally last a little longer than those of a lubricant.
- Use a water-based lubricant (glycerin-free versions of Astroglide, K-Y Intrigue, others) to reduce discomfort during intercourse. Choose products that don't contain glycerin because women who are sensitive to this chemical may experience burning and irritation. Avoid petroleum jelly or other petroleum-based products for lubrication if you're also using condoms. Petroleum can break down latex condoms on contact.
Bothersome symptoms that don't improve with over-the-counter treatments may be helped by:
- Topical (vaginal) estrogen. Vaginal estrogen has the advantage of being effective at lower doses and limiting your overall exposure to estrogen because less reaches your bloodstream. It may also provide better direct relief of symptoms than oral estrogen does.
- Oral estrogen. Estrogen taken by mouth enters your entire system. Ask your doctor to explain the risks vs. the benefits of oral estrogen.
Vaginal estrogen therapy comes in several forms. Because they all seem to work equally well, you and your doctor can determine which one is best for you.
- Vaginal estrogen cream. You insert this cream directly into your vagina with an applicator, usually at bedtime. Your doctor will let you know how much cream to use and how often to insert it. Typically women use it daily for one to three weeks and then one to three times a week thereafter. Although creams may offer faster relief than do other forms of vaginal estrogen, they can be messier.
- Vaginal estrogen ring. You or your doctor inserts a soft, flexible ring into the upper part of the vagina. The ring releases a consistent dose of estrogen while in place and needs to be replaced about every three months. Many women like the convenience this offers. A different, higher dose ring is considered a systemic rather than topical treatment.
- Vaginal estrogen tablet. You use a disposable applicator to place a vaginal estrogen tablet in your vagina. Your doctor will let you know how often to insert the tablet. You might, for instance, use it daily for the first two weeks and then twice a week thereafter.
Systemic estrogen therapy
If vaginal dryness is associated with other symptoms of menopause, such as moderate or severe hot flashes, your doctor may suggest estrogen pills, patches or gel, or a higher dose estrogen ring along with a progestin. Progestin is usually given as a pill, but combination estrogen-progestin patches also are available. Talk with your doctor to decide if hormone treatment is an option for you, taking into account any medical issues and family medical history.
Researchers are working to develop other treatments for vaginal atrophy because of concerns about the long-term potential for even small doses of estrogen to increase the risk of breast and endometrial cancer.
If you've had breast cancer
If you have a history of breast cancer, tell your doctor and consider these issues:
- Nonhormonal treatments. Try moisturizers and lubricants as a first choice.
- Vaginal estrogen. In consultation with your cancer specialist (oncologist), your doctor might recommend low-dose vaginal estrogen if nonhormonal treatments don't help your symptoms. However, there is some concern that vaginal estrogen might increase your risk of the cancer coming back, especially if your breast cancer was hormonally sensitive.
- Systemic estrogen therapy. Systemic estrogen treatment generally isn't recommended, especially if your breast cancer was hormonally sensitive.
If you're experiencing vaginal dryness or irritation, these measures may provide some relief:
- Try an over-the-counter moisturizer (Replens, Vagisil Feminine Moisturizer, others). This can restore some moisture to your vaginal area.
- Use an over-the-counter water-based lubricant (glycerin-free versions of Astroglide, K-Y Intrigue, others). This can reduce discomfort during intercourse.
- Allow time to become aroused during intercourse. The vaginal lubrication that results from sexual arousal can help reduce symptoms of dryness or burning.
Some alternative medicines are used to treat vaginal dryness and irritation associated with menopause, but few approaches are backed by evidence from clinical trials. Interest in complementary and alternative medicine is growing, and researchers are working to determine the benefits and risks of various alternative treatments for vaginal atrophy.
Talk with your doctor before taking any herbal or dietary supplements for perimenopausal or menopausal symptoms. The Food and Drug Administration does not regulate herbal products, and some can be dangerous or interact with other medications you take, putting your health at risk.
Regular sexual activity, either with or without a partner, may help prevent vaginal atrophy. Sexual activity increases blood flow to your vagina, which helps keep vaginal tissues healthy.