Vulvovaginitis, Estrogen Deficient – Causes, Symptoms, Diagnosis, Treatment and Ongoing care
- Decreased blood flow with thinning and atrophy of the female genital tissues
- Changes from estrogen deficiency occur throughout the body; the genital tissues are especially hormone-responsive.
- Estrogen-deficient vulvovaginitis is often associated with urinary incontinence and increased urinary frequency.
- System(s) affected: Reproductive
- Predominant age: Postmenopausal females
- The average age of menopause in the US is 51.3 years.
- Also may affect lactating women
- Predominant sex: Female only
- This disorder affects all postmenopausal women to some degree.
- 20% of postmenopausal women experience symptoms severe enough to seek treatment.
No known pattern
- Decreased estrogen levels in the vagina and vulva result in decreased blood flow, lubrication, vaginal and vulvar fullness, and mechanical sensitivity.
- Vaginal mucosa becomes thin secondary to decreased vaginal cell maturation.
- Decreased cellular maturation results in decreased glycogen stores, which affects the normal vaginal flora and pH.
Estrogen deficiency due to
- Menopause (surgical or natural)
- Premature ovarian failure (chemotherapy, irradiation, autoimmune)
- Postpartum, lactation
- Medications that alter hormonal concentration such as gonadotropin-releasing hormone agonists and danazol
Commonly Associated Conditions
- Pelvic organ prolapse
- Frequent urinary tract infections
- Bacterial vaginosis or yeast infections
- Important to ask patient about symptoms because many women are embarrassed to discuss these issues with their health care providers.:
- Vaginal dryness
- Malodorous discharge
- Urinary symptoms: Dysuria, hematuria, frequency, infections, stress incontinence
- Ask about self-treatment and products used.
- Determine exposure to irritants (e.g., example, soaps, feminine sprays, lotions, etc.).
- Obese patients, especially those weighing >100 lb (45 kg) over ideal body weight, have higher levels of circulating estrogen and thus may have fewer symptoms.
- Androstenedione is converted to estrone in peripheral adipose tissue.
- When adipose tissue is abundant, higher estrone levels are present.
Evidence for the diagnosis includes the following (1)[C]:
- Decreased vulvar and vaginal fullness
- Decreased vaginal lubrication
- Pale-appearing vaginal and urethral mucosa
- Loss of vaginal rugation and decreased vulvar subcutaneous fat
Diagnostic Tests & Interpretation
Lab tests are generally unnecessary to make this clinical diagnosis. However, the following may be obtained as corroborative of clinical impression:
- Cytology for maturation index: Higher proportion of parabasal cells and lower proportion of intermediate and superficial cells indicate decreased maturation index.
- Vaginal pH usually >5
- Follicle-stimulating hormone levels are high, indicating low estrogen levels.
- Estradiol levels are low.
- Drugs that may alter lab results:
- Estrogen therapy will alter the maturation index.
- Digoxin has estrogen-like properties.
- Tamoxifen may produce menopausal-type symptoms but also may act on genital tissues as a weak estrogen agonist. Symptoms may vary.
- Drugs used to treat endometriosis or uterine bleeding, such as progestins, danazol, or gonadotropin-releasing hormone agonists, may produce a pseudomenopause, which is reversible.
- Thinning of the cornified squamous layer of both the vulva and the vagina
- Increased parabasal cells
- Compact underlying collagenous tissue
- Vulvar dystrophies
- Bacterial or yeast vulvovaginitis
- Nonhormonal therapy includes water-soluble lubricants or vaginal moisturizers (1)[C].
- Vaginal estrogen can reverse atrophic changes and help to alleviate symptoms (2,3)[A]:
- Vaginal cream (Premarin and other conjugated equine estrogens or estradiol cream): Insert via applicator each night × 14 days and then 2–3×/week.
- Vaginal estradiol tablet: Insert via preloaded applicator each night × 14 days and then 2–3×/week
- Estradiol-containing vaginal ring: Insert into vagina, and replace every 3 months.
- Vaginal estrogen preparations rather than systemic preparations should be 1st-line therapy in a woman whose primary complaint is associated with vaginal atrophy (1)[C].
- Progestin therapy or monitoring of endometrial status in a woman with an intact uterus is not necessary (1)[C].
- Estrogen therapy should be used in the lowest possible dose for the shortest duration of time.
- Long-term therapy may be necessary owing to the chronic nature of estrogen-deficient vulvovaginitis.
- Systemic therapy typically is used as hormonal treatment of vasomotor symptoms and not for the primary treatment of estrogen deficient vulvovaginitis.
- Breast or estrogen-dependent carcinoma
- Undiagnosed vaginal bleeding
- Thromboembolic disorders
- Precautions: Any abnormal vaginal bleeding must be evaluated.
- Wear loose-fitting, undyed cotton underwear.
- Avoid feminine deodorant sprays and products not intended for use in the genital area (e.g., hand lotion).
- Regular sexual activity can maintain vaginal health (1)[C].
- Use over-the-counter water-based lubricants as needed.
- Symptomatic relief if needed (e.g., cool baths or compresses)
The patient should be instructed that symptoms should improve within 30–60 days. If they do not, re-evaluation and re-examination for other causes should be undertaken.
No special diet
- American College of Obstetricians and Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188; 1 (800) 762-ACOG; http://www.acog.org
- Lactating postpartum women with high levels of prolactin are in a hypoestrogenic state. These women should be instructed to use lubrication for symptoms of dyspareunia and reassured that the symptoms will resolve when they are no longer breast feeding.
The prognosis is excellent. The vast majority of symptoms will be relieved with vaginal estrogen replacement therapy.
- Recurrent urinary tract infections may occur in women with vaginal atrophy.
- Treatment should include vaginal estrogen therapy (1)[C].
1. Johnston S, et al. The detection and management of vaginal atrophy. Int J Gynecol Obstet. 2005;88:222–8.
2. Suckling J, et al. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Sys Rev. 2006;4:CD001500.
3. Farquhar CM, et al. Long-term hormone therapy for perimenopausal and postmenopausal women.Cochrane Database Sys Rev. 2005;3:CD004143.
Mehta A, Bachmann G. Vulvovaginal complaints. Clin Obstet Gynecol. 2008;51:549–55.
- 616.10 Vaginitis and vulvovaginitis, unspecified
- 627.3 Postmenopausal atrophic vaginitis
- 53277000 vulvovaginitis (disorder)
- 75993002 atrophic vulvovaginitis (disorder)
- Estrogen-deficient vulvovaginitis affects all postmenopausal women to some degree.
- This disorder is often associated with urinary incontinence and increased urinary frequency.
- Lab tests are generally unnecessary to make the diagnosis.
- Vaginal estrogen preparations, rather than systemic preparations, should be 1st-line therapy in a woman whose primary complaint is associated with vaginal atrophy.