Written by Dr. Stavros Athanasiou

Atrophic vaginitis refers to thinning, dryness and inflammation of the vaginal tissues, usually associated with a significant decrease in oestrogen levels. These hormonal changes can also affect the normal vaginal microflora. The condition is also known as vaginal atrophy.

Oestrogen, which is produced mainly by the ovaries, plays an important role in maintaining vaginal lubrication and healthy vaginal tissues. When oestrogen levels fall, the vaginal tissues can become thinner, drier and less elastic. The vagina may also become more susceptible to irritation and inflammation in atrophic vaginitis.

Causes of Atrophic Vaginitis

In most cases, the condition is associated with a reduction in oestrogen levels.

Common causes and contributing factors include:

– Menopause, when the ovaries naturally produce less oestrogen as part of the hormonal changes associated with ageing.

– Surgical removal of both ovaries before natural menopause, known as bilateral oophorectomy. This may be performed alongside a hysterectomy, but the two procedures are different: a hysterectomy removes the uterus, while an oophorectomy removes the ovaries. Read more about the methods and types of hysterectomy.

– Medication used to lower oestrogen levels in women with certain conditions, such as uterine fibroids or endometriosis.

– Premature ovarian insufficiency, when ovarian function declines before the age of 40.

– Breastfeeding, during which oestrogen levels may temporarily be lower.

– Radiotherapy or chemotherapy, which may affect ovarian function or vaginal tissues.

Exposure to irritating substances, such as scented soaps, detergents, lotions and perfumes, can worsen vaginal discomfort, although these do not themselves cause oestrogen-related vaginal atrophy.

Certain medications and smoking may also contribute to vaginal dryness. Some women experience additional irritation from tampons, condoms or the products used with them.

Atrophic vaginitis may develop gradually, and some women may not notice symptoms initially. Discussing early changes with your doctor can help identify an appropriate approach to management.

Symptoms of Atrophic Vaginitis

Common symptoms of atrophic vaginitis include:

– Vaginal dryness.

– Vaginal itching or a burning sensation.

– Dyspareunia, meaning pain during sexual intercourse.

– Light bleeding or spotting after sexual intercourse.

– Urinary symptoms, such as frequent urination, urgency, urinary incontinence and recurrent urinary tract infections.

Diagnosis of Atrophic Vaginitis

Your doctor will initially ask whether you have reached menopause or experienced menopausal symptoms, such as absent or irregular periods, mood changes, hot flushes, difficulty sleeping or night sweats.

If you are still of reproductive age, your doctor will ask whether you are breastfeeding or experiencing irregular periods, which may be associated with low oestrogen levels or other hormonal changes. Your medical and surgical history will also be reviewed, along with any medication you are currently taking.

Your doctor may suspect atrophic vaginitis based on your symptoms, age and medical history. A gynaecological examination helps assess the vaginal tissues for signs of dryness, redness and thinning, and exclude other causes of discomfort.

If you experience bleeding after menopause, including bleeding after sexual intercourse, it should be assessed by your doctor. Depending on the findings, investigations may include a transvaginal ultrasound or an endometrial biopsy to check for conditions affecting the lining of the uterus, including endometrial cancer. During a biopsy, a small sample of the uterine lining is collected and examined in a laboratory.

How Long Does Atrophic Vaginitis Last?

Atrophic vaginitis can persist while oestrogen levels remain low. After menopause, symptoms may continue or worsen without treatment, although appropriate management can provide relief.

Atrophic Vaginitis and Prevention

A water-based lubricant can help reduce friction and discomfort during sexual intercourse. Vaginal moisturisers may also help manage ongoing dryness.

Regular, comfortable sexual activity may help maintain blood flow to the vaginal tissues. However, it does not replace treatment, and you should not continue intercourse if it causes pain.

Treatment of Atrophic Vaginitis

Atrophic vaginitis can be managed with non-hormonal products and, when appropriate, oestrogen therapy. For symptoms limited to the vaginal and urinary area, your doctor may recommend low-dose vaginal oestrogen, available as a cream, vaginal tablet or insert, or an oestrogen-releasing vaginal ring.

Systemic hormone therapy, such as tablets or skin patches, may be considered when other menopausal symptoms also require treatment. The choice depends on your symptoms, medical history and individual risks.

Vaginal oestrogen cream is applied using a suitable applicator. Vaginal tablets and inserts are used according to the prescribed schedule. Some vaginal rings remain in place for three months and gradually release oestrogen into the vaginal tissues. The instructions vary by product, so follow your doctor’s guidance.

Women may also use water-based lubricants, as mentioned earlier. These products do not contain oestrogen and are available without a prescription. Vaginal moisturisers are another non-hormonal option for regular use.

Any unexpected vaginal bleeding, particularly after menopause, should be reported to your doctor. Do not assume that bleeding is simply a normal effect of treatment.

Before prescribing oestrogen, your doctor will assess your medical history, including:

– Unexplained vaginal bleeding.

– Liver disease.

– A history of breast cancer.

– A history of endometrial cancer.

– A history of blood clots.

The suitability of treatment depends on whether oestrogen is given locally or systemically, as well as your individual circumstances. In women with a history of hormone-sensitive cancer, decisions about vaginal oestrogen may require discussion with the treating oncology team.

Women who cannot or prefer not to use oestrogen may use vaginal moisturisers and water-based lubricants to help relieve dryness and discomfort.

Treatment of Atrophic Vaginitis with MonaLisa Touch Laser

MonaLisa Touch Laser is an energy-based technique that has been offered for symptoms associated with vaginal atrophy. It applies fractional laser energy to the vaginal tissues.

However, evidence regarding its effectiveness and long-term safety remains limited. It should not be presented as a proven first-line treatment for atrophic vaginitis, vaginal laxity or urinary incontinence, and immediate symptom relief cannot be guaranteed.

If you are considering vaginal laser treatment, discuss the available evidence, potential risks and established alternatives with your doctor. Possible complications include burns, scarring, pain during intercourse and persistent pain.

Women should feel comfortable discussing vaginal dryness, irritation, itching or pain with their doctor. Atrophic vaginitis is a common condition, and an individualised assessment can help identify suitable options to improve comfort and quality of life.