Atrophic vaginitis

Disease Description (Causes and Symptoms)

Senile (atrophic) vaginitis (also called postmenopausal vaginal atrophy or genitourinary syndrome of menopause) refers to atrophic changes in the vaginal mucosa caused by estrogen deficiency after menopause and the resulting symptoms. Pathophysiologically, estrogen deficiency causes a decrease in the thickness of the vaginal epithelium and glycogen → a decrease in lactobacilli and an increase in vaginal pH, making the mucosa dry and fragile. The main symptoms are as follows.

• Vaginal dryness, burning, and pruritus (itching)
• Dyspareunia (pain during sexual intercourse) and discomfort related to decreased sexual desire
• Abnormal vaginal discharge (including yellow or pink-tinged bleeding) or contact bleeding
• Urinary symptoms: pain during urination (dysuria), urinary frequency, urinary urgency, urinary incontinence, or an increased incidence of recurrent urinary tract infections
  Clinically, it must be differentiated from infectious vaginitis and cancer (particularly when abnormal bleeding is present).

Treatment Methods

• Local hormone therapy
  • Low-dose local vaginal estrogen (cream, vaginal tablet, oral/vaginal insert, or ring): Most effective for restoring the vaginal mucosa and improving discharge, pain, and dryness. A standard first-line treatment option.
  • According to the information provided in the table, locally applied vaginal estrogen is known not to increase the risk of breast cancer; however, those with a history of breast cancer should consult their treating physician.
• Systemic hormone replacement therapy (HRT)
  • Considered when systemic menopausal symptoms are also present or systemic treatment is needed. The benefits and risks of systemic administration should be individually assessed.
• Nonhormonal treatment
  • Water-based lubricants (for use during sexual intercourse) and vaginal moisturizers (regular use) — helpful for immediate symptom relief and long-term moisturization.
  • Regular sexual intercourse or self-stimulation (helps maintain blood flow and mucosal health).
  • Physical therapy (pelvic floor muscle strengthening) and treatment to improve urinary function (such as bladder training) — useful for urinary symptoms.
• Medication alternatives/complementary options
  • Oral SERM (e.g., Ospemifene): May be used for postmenopausal dyspareunia (related to vaginal atrophy) (the indication and contraindications for use should be confirmed).
  • Intravaginal DHEA (prasterone): Used in some countries to improve dyspareunia.
• When infection is also present
  • If a bacterial infection is confirmed, appropriate antibiotic treatment. Antibiotics are not needed for simple atrophic changes.
• Other procedures
  • Laser or energy-based devices (vaginal laser): Some symptom improvement has been reported, but evidence for long-term safety and effectiveness remains limited, and this is not a first-line treatment.
• Treatment course and follow-up
  • Local estrogen generally improves symptoms within several weeks. This is a chronic condition requiring maintenance therapy. Assess the course within 4–12 weeks after starting treatment and establish a plan for continued treatment if needed.

Precautions / Risk of Complications / Self-Care Considerations

• Medical evaluation is needed if new symptoms such as abnormal vaginal bleeding, persistent pain, or foul-smelling discharge occur (bleeding may indicate the need for cancer testing).
• Those with a history of breast cancer or suspected estrogen-dependent tumors must consult a specialist (medical oncologist/obstetrician-gynecologist) before hormone therapy.
• With local estrogen use, local irritation or minor systemic effects (such as breast tenderness) may rarely occur.
• Hygiene: Avoid excessive use of vaginal cleansing products and irritating products.
• Use of lubricant during sexual intercourse is recommended.
• Complications: recurrent infections, vaginal bleeding, chronic sexual dysfunction, and worsening urinary symptoms.

Outpatient Visit Checklist (Including Example Questions)

Items to bring/submit if possible

• List of currently used medications (especially hormones, anticoagulants, anticancer drugs, antibiotics, SERMs, etc.)
• Personal and family history of breast cancer, endometrial cancer, thrombosis, etc.
• Results of recent tests (recent Pap smear, culture tests, history of hormone therapy, etc.)
• Record of when symptoms started and factors that worsen or improve them (whether there is pain during sexual intercourse, the color, smell, and amount of discharge, and urinary symptoms)
• Allergy history and information about currently used vaginal lubricants/moisturizers

Information to tell the doctor first during the outpatient visit (examples)

• Whether there has been recent bleeding (especially bleeding after menopause)
• A history of breast cancer or estrogen-dependent disease
• Whether there are current cardiovascular disease or thrombosis risk factors (such as smoking or obesity)

General Example Questions to Ask the Doctor

• When should the expected effects of this treatment (local estrogen) begin? How long should I use it?
• What are the main side effects of this medication? Does it increase the risk of breast cancer?
• What alternative treatment options are available if I cannot receive hormone therapy?
• If my symptoms do not improve, what tests or procedures would be next?

Examples of Condition-Specific Questions

• I have a history of breast cancer. Is it safe for me to use local vaginal estrogen? (If necessary, consultation with medical oncology is recommended.)
• How should vaginally applied estrogen (cream/tablet/ring) be used (directions and dosage), and what regular tests should I undergo during treatment?

(End)