During menarche, pregnancy, and lactation, and after menopause, the vaginal epithelium lacks the stimulation of estrogen. The maturation of the vaginal and urethra mucosa depends on the presence of estrogen and can be altered by the absence of estrogen or the presence of anti-estrogenic factors, such as hormones, drugs, or diseases. Menopause results in a vaginal mucosa that is attenuated, pale, and almost transparent as a result of decreased vascularity. The vagina loses its normal rugae. The squamous epithelium atrophies, the glycogen content of the cells decreases, and the vaginal pH ranges from 5.5 to 7.0. The mucosa is only three or four cells thick and is less resistant to minor trauma and infection. Marked atrophic changes can cause atrophic vaginitis. It is important to distinguish between symptomatic atrophic vaginitis, which is rare, and an atrophic vagina that is a result of physiologic changes of menopause. When symptomatic vaginitis occurs, the vaginal epithelium is thin, inflamed, and even ulcerated. Symptoms include vaginal soreness, dyspareunia, and occasional spotting or discharge, which may be a thin, scant, yellowish or pink material. The cervix atrophies and retracts and may become flush with the apex of the vault. The upper one-third of the vagina constricts, and the entire vagina becomes shorter in length and loses its elasticity. The increased vaginal pH may permit the growth of nonacidophilic coliform organisms, bacteria not normally found in the vagina, and the disappearance of Lactobacillus species. This can lead to the development of a clinical vaginal infection with copious purulent discharge. Unless estrogenic replacement therapy is used, Candida and Trichomonas infections are rare. The changes seen vary widely from one patient to another.
A Papanicolaou (Pap) smear of the cervix and vagina is mandatory in the face of bleeding to rule out carcinoma. A wet preparation will show erythrocytes and increased PMNs associated with small, round epithelial cells, which are immature squamous cells that have not been exposed to sufficient estrogen.
The treatment of atrophic vaginitis consists primarily of topical vaginal estrogen. Nightly use of vaginal tablets is effective. Estradiol absorption from vaginal tablets has been found to be negligible when low dose formulations (10 to 25 ug) are used.Estrogen should not be prescribed for any patient with a past history of cancer of any of the reproductive organs. Atrophic vaginitis is usually not seen in patients who are already on systemic estrogen replacement therapy. Patients should be referred for follow-up to monitor therapy and for the results of the Pap smear.
Revision date: July 5, 2011
Last revised: by Jorge P. Ribeiro, MD