AKT · Obstetrics & gynaecology/Menopause & vulvallow yield

Genitourinary syndrome of menopause

Urogenital oestrogen deficiency (vaginal atrophy)

Overview

The cluster of vaginal and urinary symptoms from oestrogen deficiency after menopause (formerly "atrophic vaginitis") — dryness, dyspareunia, irritation and recurrent urinary symptoms, responsive to vaginal oestrogen.

Recognise

Vaginal dryness, itch, burning, dyspareunia
Pale, thin, dry vaginal epithelium with loss of rugae
Recurrent UTIs, urinary frequency/urgency

Red flags

Postmenopausal bleeding must not be attributed to atrophy until cancer is excluded

Differentials & how to tell them apart

Lichen sclerosuswhite atrophic figure-of-eight plaques, intense itch

Vulvovaginal candidiasisdischarge, itch, normal pH

Vulval cancerpersistent lump/ulcer — biopsy

Contact dermatitisirritant exposure

Investigations

Clinical. Exclude infection and (if any PMB) endometrial cancer.

Management

Topical vaginal oestrogen (± moisturisers/lubricants)

1Vaginal (topical) oestrogen — effective and can be continued long-term; add lubricants/moisturisers.
2Systemic HRT also helps; vaginal oestrogen can be added to it for persistent local symptoms.

Vaginal oestrogen — first-line; can be used long-term, even alongside systemic HRT

Vaginal moisturisers/lubricants — non-hormonal

Key points

Vaginal oestrogen is low-dose/local and does not require added progestogen for endometrial protection.

Monitor & prognosis

Symptom relief; exclude other causes if not improving.

Responds well; recurs if treatment stopped.

Source: NICE NG23; CKS