Atrophic vaginitis

Definition

• Atrophic vaginitis is part of the genitourinary syndrome of menopause (GSM), which comprises the genital, sexual and urinary changes resulting from oestrogen deficiency.
• The vagina, labia, urethra and bladder are affected.

Occurrence & epidemiology

Epidemiology

• Reported prevalence among postmenopausal women ranges from 14 to 87 %; a recent review gives about 40 % of postmenopausal women for vulvovaginal atrophy.
• Unlike vasomotor symptoms, the genitourinary changes progress with ageing.

Aetiopathogenesis

Aetiology and risk factors

• The cause is oestrogen deficiency, mainly after the menopause, but also during lactation, with hypothalamic amenorrhoea and with primary ovarian insufficiency.
• As oestrogen falls, glycogen and lactobacilli decline, the pH rises above 5, and the epithelium becomes thinner, less elastic and less vascular.

Clinical features

Findings (Case File 141)

• What is seen on speculum examination: pale, smooth, vulnerable mucosa.
• Typical accompanying symptoms: dryness, burning, itching, dyspareunia.
• A wet mount shows: parabasal cells, elevated pH.
• Why the atrophy develops: oestrogen deficiency: thinner epithelium, glycogen loss.
• Additional consequences: urinary tract infections and urgency.

Accompanying menopausal symptoms

• Cardinal symptom: hot flushes and sweating, i.e. vasomotor symptoms.
• Other common complaints: sleep disorders, mood swings, loss of libido.
• The genitourinary syndrome: vaginal dryness, dyspareunia, recurrent UTIs.
• What affects almost everyone, but is noticed late: accelerated bone loss.

• Typical symptoms are vaginal dryness, burning and irritation, pain during intercourse, and urinary urgency, frequency and dysuria.
• Recurrent urinary tract infections and bleeding during intercourse may also occur.

Diagnosis

Typical imaging findings

• Colposcopy: The cervix is strikingly pale, the epithelium looks thin and translucent, and the os is narrow and hard to probe. Pinpoint and streak-like haemorrhages are scattered over the surface and the adjacent vaginal wall; there is no circumscribed tumour.

• The mucosa appears pale, thin and dry, with reduced rugae, petechiae and increased friability.
• Vaginal pH is typically above 5, although this also occurs in bacterial vaginosis; the maturation index shows a predominance of immature parabasal cells.

Keep learning in the app

Further reading (selection)

1. StatPearls: Genitourinary Syndrome of Menopause (NCBI Bookshelf)
2. Urinary manifestations of genitourinary syndrome of menopause (Gynecol Pelvic Med 2026, PubMed Central)
3. DocCheck Flexikon, Kolpitis
4. DocCheck Flexikon, Klimakterium

Cross-references