Vaginal Atrophy: Symptoms, Types, Causes and Treatment

Vaginal atrophy, also known as vulvovaginal atrophy (VVA) or genitourinary syndrome of menopause (GSM), is a common but under-recognized condition affecting millions of women, especially after menopause. This article provides a comprehensive overview of vaginal atrophy, focusing on its symptoms, types, causes, and evidence-based treatments. Empowering women with knowledge about this condition can help reduce stigma, improve communication with healthcare providers, and promote effective management.

Symptoms of Vaginal Atrophy

Vaginal atrophy can dramatically affect quality of life, yet its symptoms are often overlooked or misattributed to normal aging. Understanding the full spectrum of symptoms is the first step toward effective care.

Symptom	Description	Impact Area	Source(s)
Dryness	Loss of vaginal moisture	Sexual health, comfort	1 4 5 7
Dyspareunia	Pain during intercourse	Sexual relationships	1 4 5 7
Irritation	Burning, itching, or soreness	Daily comfort	1 4 5 7
Urinary Issues	Frequency, urgency, incontinence, dysuria	Urinary tract health	4 5 7
Bleeding	Vaginal bleeding, especially after sex	Physical health	4 5 7

Table 1: Key Symptoms of Vaginal Atrophy

Understanding the Symptoms

Vaginal atrophy manifests in a variety of physical and emotional ways. Here’s a closer look at its main symptoms:

Vaginal Dryness and Discomfort

• Dryness is the most frequently reported symptom, with up to 100% of affected women experiencing it 1 4 5.
• Irritation, burning, and itching are also common, making daily activities uncomfortable 1 4 5.

Painful Intercourse (Dyspareunia)

• Dyspareunia—pain during sex—affects up to 78% of women with vaginal atrophy, leading to reduced sexual activity and strained relationships 1 4 5 7.
• This pain can persist or worsen if untreated.

Urinary and Bleeding Issues

• Symptoms often extend to the urinary system, resulting in urgency, frequency, urge incontinence, or painful urination (dysuria) 4 5 7.
• Bleeding or spotting, especially after intercourse or examination, can occur due to the fragile, thinned vaginal tissues 4 5.

Impact on Quality of Life

• Nearly 60% of women report that vaginal atrophy symptoms affect their enjoyment of sex, while others experience disrupted sleep, general discomfort, and changes in temperament 1.

Underreporting and Misattribution

• Many women do not recognize these symptoms as medical issues, often attributing them to normal aging rather than a treatable condition 1 10 11.
• Reluctance to discuss these symptoms with healthcare professionals remains a significant barrier to diagnosis and care 1 10 11.

Types of Vaginal Atrophy

Although the term “vaginal atrophy” is widely used, it actually encompasses a spectrum of related conditions and presentations. Recognizing these types helps tailor management to each woman's needs.

Type	Defining Features	Typical Patient Group	Source(s)
Vulvovaginal Atrophy (VVA)	Atrophy of vulva and vagina	Postmenopausal women	1 4 5 6
Genitourinary Syndrome of Menopause (GSM)	Atrophy plus urinary symptoms	Menopausal/postmenopausal	4 5 6
Atrophic Vaginitis	Atrophy with inflammation	Subset of VVA cases	6
Treatment-Induced Atrophy	Due to cancer therapies or surgeries	Cancer survivors	5

Table 2: Types of Vaginal Atrophy

Exploring the Types

Vulvovaginal Atrophy (VVA)

• VVA refers to thinning and drying of both the vaginal and vulvar tissues due to decreased estrogen, most common after menopause 1 5 6.
• Symptoms mainly involve discomfort, dryness, and pain with intercourse.

Genitourinary Syndrome of Menopause (GSM)

• GSM is a newer, broader term encompassing both vulvovaginal atrophy and associated urinary symptoms, such as urgency, frequency, and incontinence 4 5 6.
• Recognizing GSM ensures that both vaginal and urinary complaints are considered in diagnosis and treatment.

Atrophic Vaginitis

• This term is used when atrophy is accompanied by inflammation or infection, presenting with more pronounced redness, irritation, and sometimes discharge 6.
• It highlights the potential for secondary infections in atrophic tissues.

Treatment-Induced Atrophy

• Women undergoing cancer treatment (breast, pelvic cancers) or surgical menopause often experience abrupt and severe atrophy due to rapid hormonal changes 5.
• Symptoms can be more pronounced and harder to treat, especially when hormone therapies are contraindicated.

Causes of Vaginal Atrophy

Understanding what leads to vaginal atrophy is vital for prevention and management. While menopause is the most common cause, there are several other contributing factors.

Cause	Mechanism	Risk Factors	Source(s)
Estrogen Deficiency	Reduced blood flow and tissue thinning	Menopause, aging, oophorectomy	1 4 5 6
Cancer Therapies	Surgical/chemical hormone suppression	Breast/pelvic cancer treatment	5
Sedentary Lifestyle	Potential impact on circulation	Physical inactivity	4
Infection/Inflammation	Increased tissue vulnerability	Recent vaginal infections	4

Table 3: Causes of Vaginal Atrophy

The Role of Estrogen

The primary driver of vaginal atrophy is estrogen deficiency:

• Estrogen maintains vaginal tissue thickness, elasticity, and moisture. When levels drop after menopause—or due to surgical removal of the ovaries (oophorectomy)—vaginal tissues become thin, dry, and less resilient 1 4 5 6.
• Even women on systemic hormone therapy may experience localized vaginal atrophy 5.

Cancer Therapies

• Treatments for breast or pelvic cancers can induce or worsen atrophy due to surgical removal of hormone-producing tissues or the use of medications that block estrogen 5.
• These women may have limited treatment options, as local estrogen is often discouraged due to concerns about cancer recurrence 5.

Lifestyle and Other Contributors

• Sedentary lifestyle has been linked to a higher risk of developing GSM, possibly due to poorer circulation and tissue health 4.
• Recent vaginal infections or chronic inflammation can further damage fragile tissues, compounding symptoms 4.

Misconceptions and Underdiagnosis

• Many women and even healthcare providers attribute symptoms to normal aging or do not connect them to hormonal changes, leading to underdiagnosis and undertreatment 1 10 11.
• Awareness campaigns and routine gynecological screening are crucial to improve detection rates 4 10 11.

Treatment of Vaginal Atrophy

Effective management of vaginal atrophy is possible, yet many women remain untreated or dissatisfied with current therapies. Understanding the full range of options empowers women to make informed choices.

Treatment Option	Mode of Action/Use	Benefits/Limitations	Source(s)
Local Estrogen Therapy	Creams, tablets, rings; restores tissue	Highly effective, some safety concerns	2 7 9
Non-Hormonal Moisturizers/Lubricants	OTC products for symptom relief	Accessible, less effective for severe cases	1 10
DHEA (Prasterone)	Vaginal steroid precursor	Local action, few systemic effects	3 7
Laser Therapy	Fractional CO2 laser rejuvenation	Non-hormonal, promising results	8
Systemic Hormone Therapy	Oral/transdermal hormones	Not always necessary, more side effects	2 7
Lifestyle Modifications	Physical activity, infection prevention	Supportive, not curative	4

Table 4: Overview of Treatment Options

Local Estrogen Therapy

• Forms: Includes creams, tablets, pessaries, and vaginal rings 2 7 9.
• Efficacy: Consistently shown to relieve dryness, dyspareunia, and improve vaginal health markers (pH, cell types) 2 9.
• Safety: Generally safe for most women, but concerns remain about long-term use and safety in cancer survivors 2 5 9. Some products (like estriol cream) are considered safer and may be used even in women with a breast cancer history 7.
• Adherence: Many women discontinue due to messiness, need for applicators, and perceived risks 1 10.

Non-Hormonal Options

• Moisturizers and Lubricants: Readily available over the counter; provide temporary symptom relief but do not reverse tissue changes 1 10.
• Limitations: Many women report insufficient relief, especially for moderate-to-severe symptoms 1 10.

DHEA (Prasterone)

• Mechanism: A steroid precursor applied locally as a vaginal suppository; improves tissue health and reduces pain at intercourse without significant systemic effects 3 7.
• Effectiveness: Demonstrated significant improvement in vaginal dryness, pH, and tissue quality 3.
• Side Effects: Minimal, mostly limited to transient vaginal discharge 3.

Laser Therapy

• Fractional CO2 Laser: A non-hormonal modality that promotes tissue regeneration through controlled thermal injury 8.
• Results: Clinical trials show significant improvement in dryness, burning, itching, and dyspareunia after three sessions; high patient satisfaction and no major adverse effects reported 8.
• Limitations: Long-term safety and comparative efficacy data are still emerging 8.

Systemic Hormone Therapy

• Use: Not routinely required for isolated vaginal atrophy; reserved for women with additional menopausal symptoms 2 7.
• Risks: Higher risk of systemic side effects; always combined with progestogen if the uterus is present to prevent endometrial hyperplasia 7.

Lifestyle and Supportive Approaches

• Physical Activity: Regular exercise may reduce risk and support overall tissue health 4.
• Infection Prevention: Managing infections promptly can prevent worsening of atrophy 4.
• Education and Communication: Women desire accurate, accessible information and support from healthcare providers 10 11.

Barriers to Effective Treatment

• Underdiagnosis: Many women do not seek care, believing symptoms are a normal part of aging 1 10 11.
• Concerns About Safety: Fears about cancer risk and hormone exposure limit acceptance of effective therapies 1 10 11.
• Adherence Issues: Messiness, inconvenience, and lack of symptom relief lead to poor adherence, especially with local therapies 1 10.

Conclusion

Vaginal atrophy is a common, impactful, yet under-recognized condition linked to estrogen deficiency, most often seen after menopause. Its symptoms—ranging from dryness and pain during intercourse to urinary complaints—can profoundly affect quality of life, but too often go unreported and untreated.

Key Takeaways:

• Symptoms include dryness, pain with sex, irritation, and urinary issues, with significant impacts on well-being 1 4 5 7.
• Types range from classic vulvovaginal atrophy to GSM and atrophic vaginitis, each requiring tailored approaches 4 5 6.
• Causes are primarily hormonal, but lifestyle and cancer therapies contribute; underdiagnosis is common 1 4 5 6 10 11.
• Treatment options are diverse, with local estrogen therapy as the gold standard; non-hormonal, DHEA, and emerging laser therapies offer alternatives, especially for those with contraindications 2 3 8 9 10.
• Barriers include lack of awareness, reluctance to discuss symptoms, safety concerns, and poor adherence to available treatments 1 10 11.

Equipped with knowledge and proactive healthcare discussions, women can achieve better outcomes and improved quality of life when managing vaginal atrophy.