Atrophic vaginitis (now part of Genitourinary Symptoms of Menopause GSM)

Atrophic vaginitis is a vaginal condition characterised by a dry, sore, easily-torn vagina that is most often caused by hormonal changes – low oestrogen (E1 and E2) – brought on by natural or medical menopause or loss of ovarian function.  

Atrophic vaginitis is now part of a collection of menopausal vulvovaginal effects called the genitourinary syndrome of menopause (GSM), as per the International Society for the Study of Vulvovaginal Disease (ISSVD) guidelines.​1​

Being treated for oestrogen-dependent breast cancer? You get your own article here.

The ovaries and oestrogen production

Oestrogen is produced by the ovaries, so when your body stops producing it for whatever reason, the result can be atrophic vaginitis. The vagina and vulva lose elasticity, the skin becomes thin and easily damaged, becoming red, sore and irritated even just by wiping or washing.

This degradation of tissue can become untenable not just for sex or even masturbating, but for going to the toilet, wearing underwear and just moving around in some women. This is highly distressing.

The vagina and oestrogen

When oestrogen is high, superficial cells are dominant, but once you strip the body of oestrogen, parabasal cells become predominant, with far fewer intermediate and superficial cells. (Read about vaginal epithelial cell types here.)

The Vaginal Maturity Index (VMI) is used at this point to determine the degree of atrophy, or shrinkage and debility, the vagina is suffering due to hormonal influences.

The changes that occur once oestrogen gets taken out of the picture include physiological and structural modifications to the genital and vaginal area, particularly in the mucosa where reduced gland activity in both the vagina and the cervix result in the characteristic dryness.

This leads to the degeneration of tissue, decreased blood flow, a loss of elasticity, fewer rugae (the carpet-ripples of the vaginal walls), and a thinning of all tissues.

An increased (less acidic) pH is also a result, combined with lowered levels of glycogen (food for good bacteria that keep acidity levels high by producing lactic acid), leaving the vagina susceptible to infection and microbial overgrowths.

The vagina shortens and narrows. The changes in the vagina due to a lack of oestrogen and testosterone are profound. Roaming oestrogens cause cancer, since oestrogen is designed to make things grow, proliferate cells, so if you are prone to it, free oestrogen just feeds cancers.

This is why you need to be very careful, especially if you have a family history of oestrogen-fueled cancers. Talk to your health professional before starting on any regime.

Got an oestrogen-dependent cancer? See here – this applies to you too.

Atrophic vaginitis symptoms

  • Vaginal dryness
  • Painful sex (dyspareunia)
  • Vulvar and vaginal irritation
  • Itching
  • Burning
  • Discharge
  • Soreness
  • Easy tearing

You will be diagnosed using practitioner questioning of your symptoms and a gynaecological examination of your vagina, sometimes undergoing testing to eliminate other conditions.

Atrophic vaginitis treatments summary​2​

  • While lifestyle modifications are known to make inroads with atrophic vaginitis, they don’t solve the underlying issue: a lack of oestrogen. Oestrogen stimulates the vaginal, cervical and vulvar tissue, which in turn has several flow-on effects for the tissue, namely keeping it moist and functional.
  • Vaginal moisturisers, if used often, can really help, as they actually have an impact on the vaginal cells, unlike lube.
  • A hormone-free natural vaginal phyto-oestrogenic suppository like Fennelope or EstroBoost
  • Lube helps, but only so much.
  • Oestrogen therapy can only be undertaken in certain women, and those who have undertaken breast cancer treatment are excluded from most of it. This group has a harder time than most due to this exclusion (see E3 – it is widely available and thought to be safe for use in these women).
  • Oestrogen and testosterone can be used successfully in a compounded mixture – ask your doctor or gynaecologist. Testosterone works on the deeper layers of the vagina, while the oestrogen works on the surface layers.
  • Testosterone therapies – DHEA and testosterone have been trialled with some success.
  • Food – soy products are high in phytoestrogens and exert quite a pronounced oestrogenic effect, while remaining safe. While tofu and tempeh are certainly not everyone’s favourite foods, 100 grams of tofu plus a teaspoon of ground flaxseeds can keep hot flashes at bay and keep a vagina moist.
  • Vaginal lasers and radiofrequency devices to rejuvenate vaginal cells (Juliet laser, ThermiVa, Mona Lisa, etc.)

The options for increasing function of the vaginal epithelial cells are:

  • Increase systemic oestrogen levels (in the blood throughout the whole body)
  • Increase local vaginal oestrogen levels
  • Increasing testosterone levels
  • Sex and masturbating
  • General body care – quit smoking (blood vessels, dear), exercise, eat well, sleep well, use your vagina
  • Laser and radiofrequency treatments vaginally

Increasing systemic oestrogen levels

This might include hormone replacement therapy (HRT) set up by your doctor, foods, or herbal medicines.​3,4​

Increasing vaginal oestrogen levels

Here we have the plethora of creams, tablets, gels and so on, inserted vaginally to have a local effect. There are a lot available, usually by prescription only, so talk to your practitioner about what’s available in your country.

Foods that increase oestrogen levels

Food provides you with a safe and sustainable way to keep your oestrogen levels up without going to too much effort or expense. These are phyto-oestrogens, which  are found in soy-based products (tempeh, tofu), among several other foods (but mainly soy).​5​

Lifestyle modifications known to improve atrophic vaginitis​6​

  • Smoking makes capillary refill harder for your blood vessels, and good blood flow is directly linked with vaginal moistness
  • Regular sex, masturbating and being physically intimate increase vaginal blood flow and regulate pH.
  • Vaginal penetration with well-lubricated vaginal dilators and fingers may help to gently stretch out tight vaginal walls.
  • Stress related to penetration should be managed where possible – practice, relax, try again, get help, try something else. It’s worth it.

If you have atrophic vaginitis, avoid:

  • Never douche, use artificial, harsh or heavily perfumed soaps or deodorisers.
  • Any soap, cream, substances that is coloured, flavoured, full of toxic chemicals and preservatives.
  • Clothes made of synthetic materials.
  • Poor quality, chemically-based laundry detergent or fabric softeners
  • You can’t treat your new, more delicate vagina like you used to, so be gentle – rough play will inevitably cause damage that will need to heal (and it will be slow).

Treatments to try

Natural vaginal restoratives

Restoring function and performance to vaginal cells can be achieved with vaginal treatments that use specific plant oestrogens, such as fennel and pomegranate. Fennel is scientifically proven to strengthen and thicken vaginal epithelial cells, alleviating many vaginal symptoms. Use as needed. Options are to make your own recipes at home, or if that’s not your thing, order the premade versions, Fennelope (moderate) and EstroBoost (strong), both of which are made at My Vagina with vagina-safe all-natural plant oils.​7​

Vaginal moisturisers

Vaginal moisturisers are designed to be just like vaginal secretions in as many ways as possible, and used on a regular basis, can be effective. Research shows that polycarbophil-based non-hormonal moisturisers are more effective than lube, and as effective as vaginal oestrogen creams as improving moisture levels, fluid volume, pH and elasticity in the vagina.

Moisturisers work by reducing dryness, itching and pain on penetration. Many vaginal moisturisers contain bioadhesive polymers that transport up to 60 times their mass in water.

These polymers binds to the vaginal cells, and release water and electrolytes which dilate the blood vessels, leading to greater hydration. The polymer is also mildly acidic, which keeps the pH of the vagina stable and acidic, though this effect (according to research) is not long-lasting.

There are many vaginal moisturisers on the market, including some excellent natural products, so shop around and find one that works well for you.

Lubricants

Lube is short-acting, and while it smooths the tissues somewhat, it doesn’t have the same qualities as a vaginal moisturiser. Lube is usually applied during sex to reduce friction and possibilities of damage, but can be used to also reduce irritation from clothing.

Water-based lubricants may not offer the required levels of comfort, so using a product that contains glycerin such as Astroglide or KY Extended might help more than say KY Jelly.

Silicone lubricant may last for a longer time than either water- or glycerin-based products, for example KY Liquibeads, or a variety of others on the market.

A good combination that seems to work well for many women is to insert polycarbophil gel into the vagina from between four and seven days days per week, and use quite a lot of glycerin-based lube before and during sex.

Oestrogen-based therapy for breast cancer survivors

The safety of oestrogen creams intravaginally continues to be heavily debated, since the levels of oestrogen that are absorbed vary considerably between women and products.

Since most oestrogen-dependent breast cancers are treated by removing the oestrogen fuel, it is concerning to even drop a small amount of oestrogen into the blood supply.

If this is a route that is taken, it is usually done with a three-month high-dose treatment period to heal the vaginal tissues completely, and then remain on the lowest possible maintenance dose ongoing after tapering down.

Scandinavian and Stockholm breast cancer research studies both closed early after a recurrence was found in cancers after taking an E1 product orally, with twice as many women in the HRT group developing cancers again for the Scandinavian group, but not the Stockholm group.

It has been determined to not be worth the risk. For safe treatments, check out atrophic vaginitis for breast cancer survivors.​8​

Vaginal hormone products

Some creams containing E3 (oestriol) are being studied for a variety of issues, including atrophic vaginitis. Speak to your healthcare provider to see if an oestrogen cream applied vaginally would be beneficial for you.

These E3 creams look very promising, since E1 and E2 can feed oestrogen-dependent cancers, whereas E3 provides the local benefits to the vagina without the danger.

Vaginal oestrogen still provides the best results of any solution available, and come in a variety of forms, from rings, to creams, to gels, to pessaries, to tablets.​9​

Tests are regularly conducted on new and novel ways of delivering oestrogen to the local vaginal tissues without it being absorbed into the bloodstream, or for activating oestrogen receptors without triggering off the cancer cascade.

Testosterone therapy

Androgen receptors exist in the vagina and vulva, meaning that testosterone could offer some hope, since it actually also converts into oestrogen, improving oestrogen levels. It does, however, cause proliferation of the endometrium.

In studies, vaginal testosterone was applied to the inner labia, the vaginal entrance and the inside of the vagina for a month with success in treating vaginal atrophy.​10​

DHEA, a form of testosterone, was also studied. DHEA binds to oestrogen and androgen receptors in the vaginal tissues, with the treatment resulting in stronger vaginal layers all the way through to the muscle layer, and reversed vaginal atrophy without increasing blood levels of androgens.

Olive Oil, Vaginal Exercise, and Moisturiser – OVERcome Study

This study looked at how to improve quality of life, sexual function and painful sex on breast cancer survivors, with significant improvements noted.​11​

Read more about the OVERcome study here.

What suits you will be individual, so try all of them! See which ones you like the best, and what works for you. There is no right or wrong answer, just a moist vagina.

Vaginal laser and radiofrequency treatments

Laser and radiofrequency treatments work on the outer and deeper layers of the vaginal tissue, increasing tone of the vaginal walls, with a renewal of cells​12​. Treatments are expensive, but are great for vaginal laxity, stress urinary incontinence, dryness and irritation.

Treatments do need to be repeated every year, since the cells renew themselves, and in menopause, tend to degrade faster. These treatments are extremely safe, noninvasive, pain-free, blood-free, and there is no downtime.

References

  1. 1.
    Castelo-Branco C, Cancelo MJ, Villero J, Nohales F, Juliá MD. Management of post-menopausal vaginal atrophy and atrophic vaginitis. Maturitas. Published online November 2005:46-52. doi:10.1016/j.maturitas.2005.06.014
  2. 2.
    Nappi RE, Martini E, Cucinella L, et al. Addressing Vulvovaginal Atrophy (VVA)/Genitourinary Syndrome of Menopause (GSM) for Healthy Aging in Women. Front Endocrinol. Published online August 21, 2019. doi:10.3389/fendo.2019.00561
  3. 3.
    Shen J, Song N, Williams CJ, et al. Effects of low dose estrogen therapy on the vaginal microbiomes of women with atrophic vaginitis. Sci Rep. Published online April 22, 2016. doi:10.1038/srep24380
  4. 4.
    Lynch C. Vaginal Estrogen Therapy for the Treatment of Atrophic Vaginitis. Journal of Women’s Health. Published online October 2009:1595-1606. doi:10.1089/jwh.2008.1281
  5. 5.
    Domínguez-López I, Yago-Aragón M, Salas-Huetos A, Tresserra-Rimbau A, Hurtado-Barroso S. Effects of Dietary Phytoestrogens on Hormones throughout a Human Lifespan: A Review. Nutrients. Published online August 15, 2020:2456. doi:10.3390/nu12082456
  6. 6.
    Sowers MR, Crawford S, McConnell DS, et al. Selected Diet and Lifestyle Factors Are Associated with Estrogen Metabolites in a Multiracial/Ethnic Population of Women. The Journal of Nutrition. Published online June 2006:1588-1595. doi:10.1093/jn/136.6.1588
  7. 7.
    Li D, Zhang T, Yang H, Yang W, Zhang C, Gao G. Effect of Vitamin D on the Proliferation and Barrier of Atrophic Vaginal Epithelial Cells. Molecules. Published online September 13, 2023:6605. doi:10.3390/molecules28186605
  8. 8.
    Lester J, Pahouja G, Andersen B, Lustberg M. Atrophic Vaginitis in Breast Cancer Survivors: A Difficult Survivorship Issue. JPM. Published online March 25, 2015:50-66. doi:10.3390/jpm5020050
  9. 9.
    Archer DF, Kimble TD, Lin FDY, Battucci S, Sniukiene V, Liu JH. A Randomized, Multicenter, Double-Blind, Study to Evaluate the Safety and Efficacy of Estradiol Vaginal Cream 0.003% in Postmenopausal Women with Vaginal Dryness as the Most Bothersome Symptom. Journal of Women’s Health. Published online March 2018:231-237. doi:10.1089/jwh.2017.6515
  10. 10.
    Fernandes T, Costa-Paiva LH, Pedro AO, Baccaro LFC, Pinto-Neto AM. Efficacy of vaginally applied estrogen, testosterone, or polyacrylic acid on vaginal atrophy: a randomized controlled trial. Menopause. Published online July 2016:792-798. doi:10.1097/gme.0000000000000613
  11. 11.
    Juraskova I, Jarvis S, Mok K, et al. The Acceptability, Feasibility, and Efficacy (Phase I/II Study) of the OVERcome (Olive Oil, Vaginal Exercise, and MoisturizeR) Intervention to Improve Dyspareunia and Alleviate Sexual Problems in Women with Breast Cancer. The Journal of Sexual Medicine. Published online October 1, 2013:2549-2558. doi:10.1111/jsm.12156
  12. 12.
    Wańczyk-Baszak J, Woźniak S, Milejski B, Paszkowski T. Genitourinary syndrome of menopause treatment using lasers  and temperature-controlled radiofrequency. pm. Published online 2018:185-189. doi:10.5114/pm.2018.81743


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Jessica Lloyd - Vulvovaginal Specialist Naturopathic Practitioner, BHSc(N)

Jessica is a degree-qualified naturopath (BHSc) specialising in vulvovaginal health and disease, based in Melbourne, Australia.

Jessica is the owner and lead naturopath of My Vagina, and is a member of the:

  • International Society for the Study of Vulvovaginal Disease (ISSVD)
  • International Society for the Study of Women's Sexual Health (ISSWSH)
  • National Vulvodynia Association (NVA) Australia
  • New Zealand Vulvovaginal Society (ANZVS)
  • Australian Traditional Medicine Society (ATMS)
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