Symptoms

With moderate to severe vaginal atrophy, you may experience the following vaginal and urinary signs and symptoms:

• Vaginal dryness
• Vaginal burning
• Burning with urination
• Urgency with urination
• More urinary tract infections
• Urinary incontinence
• Light bleeding after intercourse
• Discomfort with intercourse
• Shortening and tightening of the vaginal canal

When to see a doctor By some estimates, about half of postmenopausal women experience vaginal atrophy, although few seek treatment. Many resign themselves to the symptoms or are embarrassed to broach the topic with their doctors.

Make an appointment to see your doctor if you experience painful intercourse that's not resolved by using a vaginal moisturizer (Replens, others) or water-based lubricant (Astroglide, K-Y, others), or if you have vaginal symptoms, such as unusual bleeding, discharge, burning or soreness.

Causes

Vaginal atrophy is caused by a decrease in estrogen production. Less circulating 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 (perimenopause), 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 helps you maintain healthy vaginal tissues.

Risk factors

Certain factors may contribute to vaginal atrophy. Among these are:

• Smoking. Cigarette smoking impairs blood circulation, depriving the vagina and other tissues of oxygen. Decreased blood flow to your vagina contributes to atrophic changes. Smoking also reduces the effects of naturally occurring estrogens in the body. In addition, women who smoke have an earlier menopause and are less responsive to estrogen therapy in pill form.
• Never giving birth vaginally. Researchers have observed that women who have never given birth vaginally are more prone to vaginal atrophy than are women who have had vaginal deliveries.

Complications

With vaginal atrophy, your risk of vaginal infections (vaginitis) increases. Atrophy leads to a change in the acidic environment of your vagina, making you more susceptible to infection with bacteria, yeast or other organisms.

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. Although stress incontinence is common among menopausal women, it doesn't appear to be caused by vaginal atrophy. The connection between estrogen deficiency and urinary problems remains unclear.

Appointment

Your primary care provider may refer you to a specialist (gynecologist) to evaluate your condition.

Questions your doctor may ask Your doctor will ask questions about the symptoms you're experiencing 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 or vitamin supplements do you take?
• Have you tried any over-the-counter moisturizers or lubricants?

Tests and diagnosis

Diagnosis of vaginal atrophy may involve:

• A 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.
• A Pap test, which involves collecting a sample of cervical cells for microscopic examination. Your doctor may also take a sample of vaginal secretions or place a paper indicator strip in your vagina to tests its acidity.
• A urine test, which involves collecting and analyzing your urine, if you have associated urinary symptoms.

Treatments and drugs

Mild symptoms of vaginal atrophy may be relieved by use of an over-the-counter lubricant or moisturizer.

If symptoms are bothersome, however, either topical (vaginal) or oral estrogen is effective in relieving vaginal dryness and itchiness, and improving vaginal elasticity. Vaginal estrogen has the advantage of being effective at lower doses and limiting your overall exposure to estrogen. Estrogen applied to the vagina can still result in estrogen reaching your bloodstream, but the amount is minimal. Vaginal estrogen may also provide more direct relief of symptoms.

You should experience noticeable improvements after a few weeks of estrogen therapy. Some symptoms of severe atrophy may take longer to resolve.

If you have a history of breast cancer, oral estrogen therapy generally isn't recommended as it might stimulate cancer cell growth, especially if your breast cancer was hormonally sensitive. Whether low-dose vaginal estrogen is safe for breast cancer survivors is controversial. It's not known whether even a small increase in the level of estrogen circulating in your bloodstream may increase your risk of the cancer coming back. You might choose nonhormonal treatments, such as moisturizers and lubricants, instead.

Topical 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 suited to your preferences.

• Vaginal estrogen cream (Estrace, Premarin, others). 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, usually a daily application for the first few weeks and then two or three times a week thereafter. Although creams may offer more immediate relief than do other forms of vaginal estrogen, they can be more messy.
• Vaginal estrogen ring (Estring). A soft, flexible ring is inserted into the upper part of the vagina by you or your doctor. 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.
• Vaginal estrogen tablet (Vagifem). 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.

Oral 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 to your doctor to decide if hormone treatment is an option and, if so, which type is best for you.

Home remedies

If you're experiencing vaginal dryness or irritation, the following measures may provide some relief:

• Try a vaginal moisturizer, such as K-Y Silk-E, Me Again or Very Private, 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, such as Astroglide or K-Y, to reduce discomfort during intercourse. Avoid petroleum jelly or other petroleum-based products for lubrication if you're also using condoms. Petroleum can break down latex condoms on contact.
• Allow time to become aroused during intercourse.

Alternative medicine

A variety of 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. Here are some of the approaches under investigation:

• Black cohosh. Black cohosh is an herbal supplement that's often used to treat menopausal symptoms, particularly hot flashes. But it doesn't seem to work for vaginal atrophy. A yearlong trial of about 350 women experiencing menopausal symptoms was published by the North American Menopause Society. The trial compared black cohosh and other herbal supplements with a sham pill (placebo). The investigators found that the herbal supplements including black cohosh were not effective in treating vaginal atrophy.
• Isoflavones. These are plant-derived compounds that have estrogen-like properties (phytoestrogens). The supplements are usually extracted from soy and red clover. They may be helpful for certain menopausal symptoms, including vaginal atrophy, but the evidence is still slim. Be careful using phytoestrogen supplements if you have an increased risk of a disease or condition that's affected by hormones, such as uterine fibroids, endometriosis, or breast, uterine or ovarian cancer. Also, be cautious if you're already taking a medication that increases your level of estrogen, such as birth control pills, hormone therapy or tamoxifen.
• Vitamin D. There's some evidence that vitamin D may help relieve vaginal dryness, although more study is needed. Vitamin D also helps your body absorb calcium, which can help prevent bone loss associated with menopause. You can get vitamin D from sunlight, fortified milk, breakfast cereals and other fortified foods, and supplements.
• Dehydroepiandrosterone (DHEA). This is a natural steroid produced by your adrenal gland that's converted into estrogen and testosterone. With aging, the level of DHEA declines in women, suggesting this depletion may have something to do with age-related problems. Some studies show that intravaginal DHEA tablets help to reverse vaginal atrophy without increasing levels of circulating estrogen. But these positive results need to be duplicated before they can be considered standard therapy.

Prevention

Regular sexual activity, either with or without a partner, can decrease problems with vaginal atrophy. Sexual activity enhances blood flow to your vagina, which helps keep vaginal tissues healthy.