Clinical manifestations and diagnosis of genitourinary syndrome of menopause (vulvovaginal atrophy)
- Gloria Bachmann, MD
Gloria Bachmann, MD
- Interim Chair
- Department of Obstetrics, Gynecology & Reproductive Sciences
- Rutgers Robert Wood Johnson Medical School
- Richard J Santen, MD
Richard J Santen, MD
- Professor of Medicine
- University of Virginia Health Sciences Center
Vaginal atrophy (also referred to as vulvovaginal atrophy, urogenital atrophy, or atrophic vaginitis) is characterized by dryness, inflammation, and thinning of the epithelial lining of the vagina and lower urinary tract due to loss of estrogen. Since vaginal atrophy often involves vulva and lower urinary tract, the term genitourinary syndrome of menopause has been introduced in those instances linked to menopause . Although vaginal atrophy typically occurs in menopausal women, it can occur in women of any age who experience a decrease in estrogenic stimulation of the urogenital tissues. In premenopausal women, hypoestrogenic states include the postpartum period, lactation, hypothalamic amenorrhea, and during administration of antiestrogenic drugs.
Up to 70 percent of women with symptoms of vaginal atrophy do not discuss their condition with a health care provider . Some because they believe their symptoms are an expected and necessary part of the aging process . Cultural, religious, and societal beliefs may also play a role in making women feel uncomfortable discussing concerns related to the genitourinary system. In addition, many women are not aware of treatment options. Rather than seeking treatment, women commonly make lifestyle changes to deal with their symptoms. As an example, they may stop sexual activity due to dyspareunia caused by vaginal dryness.
Clinical manifestations and diagnosis of vaginal atrophy are reviewed here. Treatment of symptomatic vaginal atrophy, as well as use of estrogen therapy for other menopausal symptoms, is discussed in detail separately. (See "Treatment of genitourinary syndrome of menopause (vulvovaginal atrophy)" and "Treatment of menopausal symptoms with hormone therapy" and "Preparations for menopausal hormone therapy" and "Menopausal hormone therapy: Benefits and risks".)
Urogenital atrophy results from a decline in serum estrogen concentrations. In premenopausal women, estradiol is the predominant form of circulating estrogen. Serum estradiol concentrations in premenopausal women fluctuate during the menstrual cycle (figure 1), as follows:
●Early follicular phase – an average of 50 pg/mL
- Portman DJ, Gass ML, Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. Menopause 2014; 21:1063.
- Nappi RE, Kokot-Kierepa M. Women's voices in the menopause: results from an international survey on vaginal atrophy. Maturitas 2010; 67:233.
- Bachmann GA, Nevadunsky NS. Diagnosis and treatment of atrophic vaginitis. Am Fam Physician 2000; 61:3090.
- Castelo-Branco C, Cancelo MJ, Villero J, et al. Management of post-menopausal vaginal atrophy and atrophic vaginitis. Maturitas 2005; 52 Suppl 1:S46.
- Pandit L, Ouslander JG. Postmenopausal vaginal atrophy and atrophic vaginitis. Am J Med Sci 1997; 314:228.
- Lee JS, Ettinger B, Stanczyk FZ, et al. Comparison of methods to measure low serum estradiol levels in postmenopausal women. J Clin Endocrinol Metab 2006; 91:3791.
- Demers LM, Hankinson SE, Haymond S, et al. Measuring Estrogen Exposure and Metabolism: Workshop Recommendations on Clinical Issues. J Clin Endocrinol Metab 2015; 100:2165.
- Greendale GA, Judd HL. The menopause: health implications and clinical management. J Am Geriatr Soc 1993; 41:426.
- Forsberg JG. A morphologist's approach to the vagina--age-related changes and estrogen sensitivity. Maturitas 1995; 22 Suppl:S7.
- Dennerstein L, Dudley EC, Hopper JL, et al. A prospective population-based study of menopausal symptoms. Obstet Gynecol 2000; 96:351.
- Woods NF, Mitchell ES. Symptoms during the perimenopause: prevalence, severity, trajectory, and significance in women's lives. Am J Med 2005; 118 Suppl 12B:14.
- Rangiah K, Shah SJ, Vachani A, et al. Liquid chromatography/mass spectrometry of pre-ionized Girard P derivatives for quantifying estrone and its metabolites in serum from postmenopausal women. Rapid Commun Mass Spectrom 2011; 25:1297.
- Beard MK. Atrophic vaginitis. Can it be prevented as well as treated? Postgrad Med 1992; 91:257.
- North American Menopause Society. The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Menopause 2007; 14:355.
- Johnston SL, Farrell SA, Bouchard C, et al. The detection and management of vaginal atrophy. J Obstet Gynaecol Can 2004; 26:503.
- Oriba HA, Maibach HI. Vulvar transepidermal water loss (TEWL) decay curves. Effect of occlusion, delipidation, and age. Acta Derm Venereol 1989; 69:461.
- Nilsson K, Risberg B, Heimer G. The vaginal epithelium in the postmenopause--cytology, histology and pH as methods of assessment. Maturitas 1995; 21:51.
- Willhite LA, O'Connell MB. Urogenital atrophy: prevention and treatment. Pharmacotherapy 2001; 21:464.
- Selvaggi SM. Atrophic vaginitis versus invasive squamous cell carcinoma on ThinPrep cytology: can the background be reliably distinguished? Diagn Cytopathol 2002; 27:362.