Atrophic vaginitis, also known as vaginal atrophy, is a type of vaginitis primarily caused by reduced estrogen levels and decreased local resistance in the vagina, often associated with infections dominated by aerobic bacteria. It is commonly observed in women who have undergone natural or surgical menopause but may also occur in those experiencing postpartum amenorrhea or receiving drug-induced menopause therapy. The decline in estrogen levels during the menopausal transition and after menopause can lead to not only genital tract infections but also urinary tract infections and difficulties with sexual activity. The collective symptoms and signs resulting from these conditions are referred to as Genitourinary Syndrome of Menopause (GSM), and atrophic vaginitis is one of its manifestations.
Etiology
In postmenopausal women, the decline or loss of ovarian function leads to reduced estrogen levels, causing atrophy of the vaginal wall, thinning of the mucosa, decreased glycogen in epithelial cells, and an increase in vaginal pH (commonly ranging from 5.0 to 7.0). As lactobacilli are no longer dominant, local resistance diminishes, allowing overgrowth of aerobic pathogens or invasion by other pathogenic organisms, resulting in vaginitis.
Clinical Presentation
The primary symptoms include a burning sensation and discomfort in the vulva, often accompanied by itching and dyspareunia. Vaginal discharge is typically thin and pale yellow, but if the infection is severe, the discharge may become purulent or blood-tinged. Clinical examination often reveals the loss of vaginal rugae, with the vaginal walls appearing atrophic and thin. Hyperemia of the vaginal mucosa is observed, with scattered petechiae or pinpoint bleeding spots, and superficial ulcers may sometimes be present.
Diagnosis
The diagnosis is based on a history of menopause, ovarian surgery, or pelvic radiation therapy, along with clinical symptoms, while excluding other medical conditions. Microscopic examination of vaginal secretions typically shows numerous leukocytes without the presence of specific pathogens such as Trichomonas vaginalis or Candida albicans. Due to the impact of low estrogen levels, patients with atrophic vaginitis exhibit limited vaginal epithelial cell shedding, with most exfoliated cells being parabasal cells. In cases of bloody vaginal discharge, differentiation from malignancies of the reproductive tract is essential. When granulation tissue or ulcers are present on the vaginal wall, a local biopsy may be required to rule out vaginal cancer.
Treatment
The treatment strategy focuses on estrogen supplementation to enhance vaginal resistance and the use of antimicrobial agents to inhibit bacterial growth.
Estrogen Therapy
The primary treatment targets the underlying cause by supplementing estrogen, aiming to improve the vagina's anti-infective capacity. Local application of estrogen preparations, such as estriol cream, conjugated estrogen ointment, promestriene cream, or chlorquinaldol-promestriene vaginal tablets, is typically preferred.
For patients requiring hormone replacement therapy, oral estrogen supplementation may also be utilized.
Additional Treatments
Local application of antimicrobial agents or microecological modulators may help restore the vaginal microenvironment.