Vaginal atrophy: what is it and how can it be treated?

Vaginal atrophy is a common condition for women in the menopause. It is chronic and progressive and will not get better without treatment over time, unlike vasomotor symptoms (Palacios et al, 2020). Vaginal atrophy is a condition in a larger spectrum known as genital syndrome of the menopause (GSM), which incorporates physical changes in the vulva, vagina and lower urinary tract. All of the above structures have oestrogen and androgen receptors and as the oestrogen level decreases several effects are observed as shown in Table 1.

It is estimated that vaginal atrophy affects 50–80% of post-menopausal women and is caused by oestrogen deficiency (Palacios et al, 2020; Davis and Baber, 2022), but it is an under-diagnosed and under-recognised condition. This is due to many factors such as:

• Failure of health professionals to ask about the condition. Nappi et al (2016) estimated only 10% of health professionals will initiate a discussion on it
• The amount of time from the last menstrual period that it can occur, so it is sometimes not associated with the menopause (British Menopause Society (BMS), 2021)
• Women often self-treat for vaginal infections and are unaware of the diagnosis
• It can also be present in women on systemic hormone replacement therapy (HRT), so all women need to be asked about this condition.

Vaginal atrophy and lack of lubrication can also occur at any time in a woman's life and this happens in an estimated 15% of pre-menopausal women, when they are breast feeding, have hypothalamic amenorrhoea, are on the combined oral contraceptive pill, with stress, after chemotherapy and pelvic radiation, and with certain chronic conditions (Edwards and Panay, 2016).

Signs and symptoms

The main symptoms of vaginal atrophy are vaginal dryness and irritation (Palacios et al, 2020; BMS, 2021). Table 2 shows the whole range of symptoms that can occur.

The symptoms have a negative impact on quality of life, daily functioning and sexual function and may lead to psychosexual issues and problems with relationships. It can have an impact on quality of life, such as pain with walking and sitting, and may lead to women avoiding having or attending for cervical screening and other gynaecological investigations.

Investigations/differential diagnosis

The first step in getting a diagnosis is asking the right questions. Useful questions to ask are:

• Do you have any vulval/vaginal dryness, burning, pain or irritation?
• Do you have pain with sexual activity, walking or sitting?
• Any pain when passing urine?

Any health professional who is seeing women in any healthcare setting should be familiar with the condition and the questions to ask (BMS, 2022).

When considering vaginal atrophy the list of symptoms can guide the diagnosis. However, an examination may be needed to rule out other causes such as vaginal infections or urine infections, or vaginal skin conditions such as lichen sclerosis and contact dermatitis (BMS, 2021), and to confirm the signs that are listed in Box 1.

Box 1.Signs of atrophy

• Less secretions
• Loss of vaginal folds
• Less elasticity in the vaginal walls
• Vaginal walls will seem pale, with erythema, fragile tissue on examination
• Narrow introitus
• Reduction of the fat around the labia
• Vaginal mucosa is thinner and more prone to trauma, this leads to pain and bleeding with examinations and sexual intercourse and may lead to avoidance of both

Management

The treatment used is related to the women's choice and medical history. Women with a history of hormone-related cancer will have some different needs and are discussed later in the article.

The aims of treatment are to promote comfort and ensure that the symptoms are reduced. This can be by restoring the vaginal pH to under 5.5, encouraging a healthy microflora and increasing the superficial epithelial cells.

Lifestyle

Women should be encouraged to stop smoking as this can help reduce the symptoms by increasing metabolism of oestrogen (BMS, 2021). It can also be helpful to use pH neutral washes and wear looser clothing (Palacios et al, 2015).

Increasing sexual intercourse can help to reduce the symptoms, which can increase the blood flow to the mucosa and cause stretching of the tissues (BMS, 2021). If a woman is not sexually active, she could use sex toys and tissue stretching and vulva massage (Palacios, 2009).

Stress reduction can also help, as can psychosexual counselling if the vaginal atrophy has had an effect on relationships (Kingsberg and Krychman, 2013).

Non-hormonal methods

Non-hormonal therapies are either lubricants or moisturisers. These are sold over-the-counter and they can be used individually or in combination. Women may need to try a few different products before they find one that they like and suits their needs, and does not cause issues such as irritation or contact dermatitis (Edwards and Panay, 2016). They can be used with oestrogen vaginally, but should be used at different times of the day, as lubricants may impede the absorption of oestrogen (Edwards and Panay, 2016).

Lubricants

The lubrication used can help to decrease friction during sex, which decreases the irritation of the atrophic tissue. Lubricants are gels or liquids and can be applied to the vagina or the vulva before sex and can be especially useful if pain with sex is the main issue. They are not absorbed and are quick-acting and can be water-, silicone- or mineral or plant oil-based (Table 3). Using water- and oil-based lubricants together can help as well (double glide) (BMS, 2021). Some contain parabens, which can be absorbed by the body and may cause an impact on the endocrine system. Most also have preservatives and additives that can impact on pH and cause irritation in some women (Edwards and Panay, 2016).

Moisturisers

Moisturisers are used longer term to reduce friction within the vagina. Additionally, they can be absorbed into the vaginal tissues and adhere to the vaginal lining like natural secretions (Palacios et al, 2020). These are applied regularly and the effects last 3–4 days. They can be used with lubrication as well. They are useful for women who have pain with sex and also those who have pain and discomfort daily and who want to, or need to, avoid hormones.

Moisturisers maintain moisture and acidity. Most contain water- and plant-based or synthetic polymers, as well as other ingredients that may irritate (Edwards and Panay, 2016).

A useful guide to lubricants and moisturisers is contained in the article by Edwards and Panay (2016). This gives a guide to ingredients and pH and osmolarity (which if high can cause irritation).

Lasers

Lasers are non-hormonal and are thought to improve blood supply to the epithelium. The thermal effect of the laser in the tissues causes oedema, which stimulates collagen and restructure of the vaginal tissues (BMS, 2021). The treatments are given 4–6 weekly for 3 months. However, there is a lack of long-term evidence from randomised controlled trials (RCT), and it is expensive and hard to get on the NHS.

Hormonal methods

Oestrogen

Women with menopausal symptoms may be already on systemic HRT, but an estimated 26% will still have atrophy (Palacios, 2009), so additional vaginal oestrogen may be needed. For women with only vaginal symptoms, systemic HRT is not indicated, as there are longer term risks with this such as breast cancer (Collaborative Group on Hormonal Factors in Breast Cancer, 2019). However, vaginal oestrogen is safe to use in combination with systemic HRT.

Vaginal oestrogens do not have any effect on the endometrium, so do not encourage proliferation of the endometrium, and they also have no risk of breast cancer (Davis and Barber, 2022). Long-term use is suggested by the National Institute for Health and Care Excellence (NICE, 2015).

Currently vaginal oestrogen is available as creams, vaginal pessaries, gels or vaginal rings (Table 4).

Women who use vaginal oestrogen have reported improvement in vulva and vaginal symptoms and lower urinary tract issues.

Objectively they have (Palacios et al, 2020; BMS, 2021):

• Decreased vaginal pH
• Increased lactobacilli
• Improved mucosal appearance
• Vaginal oestrogens were more effective than placebo and are safe.

There is no difference between delivery methods in terms of efficacy or safety and absorption is greatest when first used due to the atrophy (Palacios et al, 2020). It is important to stress that they may work when first used, but the full effect may not be seen for a few months (BMS, 2021). Women can be advised to avoid intercourse for an hour after using them to prevent transmission to their partner (Edwards and Panay, 2016).

Even though the absorption is low, there can be side effects such as vaginal bleeding and breast tenderness (Palacios et al, 2020), so it is important to counsel women fully (Box 2).

Box 2.Issues with vaginal oestrogen

• Relative contraindications to women with hormone-dependent breast cancer, especially those taking aromatase inhibitors
• Difficulties in use – mobility and dexterity required and obesity can be a problem
• Inability/declines to touch vulva and vagina
• Discomfort
• Concerns/anxiety over oestrogens

Dehydroepiandrosterone

Dehydroepiandrosterone (DHEA) is used daily as a vaginal pessary and works instead of oestrogen. It is a pre-cursor to testosterone – and therefore oestrogens – and can help with vaginal atrophy and libido. The mode of action is by tissue-specific enzymes in the vagina turning it into oestrogen and androgens. When monitoring the blood levels, the testosterone level is raised and oestrogen slightly raised, but not over the range for post-menopausal women. DHEA is not recommended for women with hormone-dependent cancer (Labrie and Labrie, 2013; BMS, 2021).

Ospemifene 60 mg

Ospemifene is an oral treatment that binds to oestrogen receptors. It is a selective oestrogen receptor modulator and it increases the vaginal mucosa thickness and decreases the pH. There is no effect on the endometrium, no thrombosis risk and it seems to have no effect on the breast tissue.

However, the contraindications are similar to HRT, so it should not be used on women with a history of thrombosis, breast cancer under treatment or other hormone-dependent cancers (Palacios et al, 2020). One of the side effects may be vasomotor symptoms, but this may need to be balanced with the gain from an oral treatment if vaginal oestrogen/treatment is not working (BMS, 2021).

Resources

• Menopause Matters: http://www.menopausematters.co.uk/
• British Menopause Society: http://www.thebms.org.uk/
• Premature Menopause Support Group: http://www.daisynetwork.org.uk/
• Clinical Knowledge Summaries: http://www.cks.library.nhs.uk/
• Women's Health Concern: www.womens-health-concern.org

Special considerations: after cancer

Women who have had cancer treatments can have some additional needs and issues. If the cancer is hormone-dependent, then this can bring challenges with treatment: non-hormonal methods may need to be first-line treatments. Other cancer treatments, such as chemotherapy and stem cell transplants, can cause primary ovarian insufficiency (POI), so vaginal issues always need to be discussed in these patients.

For women with gynaecological cancers, especially cervical, and those with gastrointestinal cancers, an additional impact may be seen on the vaginal tissues from pelvic radiotherapy.

For women with hormone-dependent breast cancer, the first-line treatment needs to be non-hormonal (Palacios et al, 2020). If this proves to be ineffective then oestrogen can be used if there is discussion between the woman and her oncology team. The only contraindication to vaginal oestrogen is being on aromatase inhibitors. If women are on aromatase inhibitors and have vaginal atrophy and have tried all the non-hormonal measures above, then her team could consider swapping it for tamoxifen, which may help with symptoms and if still problematic then consider using a low dosage of vaginal oestrogen as well.

Conclusion

Long-term problems or issues relating to vaginal atrophy affect many women. It is important that as healthcare professionals the right questions are asked relating to this, to help women recognise it and have some treatment. Practice nurses need to be comfortable asking these sensitive questions and be able to give advice and signpost women to relevant and up-to-date information.

KEY POINTS:

• It is estimated that vaginal atrophy affects 50–80% of post-menopausal women and is due to oestrogen deficiency
• The main symptoms of vaginal atrophy are vaginal dryness and irritation
• The aims of treatment are to promote comfort and ensure that the symptoms are reduced. This can be by restoring the vaginal pH to under 5.5, encouraging a healthy microflora and increasing the superficial epithelial cells
• It is important that health professionals can ask the right questions relating to this, to help women recognise it and have some treatment

CPD REFLECTIVE PRACTICE:

• Are you confident discussing sensitive topics like vaginal symptoms with your patients? If not, could you practice having this discussion with a colleague?
• How will this article change your clinical practice?
• Where could you get extra information on this topic?