• A 50-year-old woman presents to her gynecologist reporting difficulty with intercourse. She states having vaginal dryness and pruritus. She also reports increasingly frequent hot flashes and mood swings. Her last menstrual period was 2 months ago. Pelvic exam is notable for thin and dry vaginal vestibule. There is no abnormal discharge.
  • Vulvovaginal irritation resulting from estrogen loss
    • commonly seen in menopausal women
    • commonly underdiagnosed
  • Pathogenesis
    • estrogen stimulation maintains well-epithelialized vaginal vault
      • estrogen receptors on vagina, vulva, urethra, and trigone of bladder
    • loss of estrogen results in decreased vaginal blood flow and secretions
      • vaginal tissue thinning and reduced elasticity
      • vaginal dryness and itching
      • changes in vaginal pH
  • Associated conditions
    • menopause
    • primary ovarian insufficiency
    • bilateral oophorectomy
  • Symptoms
    • vulvovaginal
      • dryness
      • burning
      • dyspareunia
    • urinary
      • urinary frequency
      • recurrent bladder infections
  • Physical exam
    • thinning of epithelial lining of vagina
    • vulvar or vaginal bleeding from fissures
  • Diagnosis by clinical history and physical exam
  • Labs
    • typically not necessary
    • vaginal pH
      • 5.5-6.8 in postmenopausal women
      • 3.5-5.0 normal
    • serum hormone levels
      • low estradiol
  • Vaginal infections
  • Vulvovaginal lichen planus
  • Vulvar lichen sclerosus
    • presents with white plaques and intense pruritus
    • treated with topical clobetasol 
  • Water-based lubricants during intercourse
  • Vaginal estrogen therapy
Prognosis, Prevention, and Complications
  • Prognosis
    • unlikely to resolve spontaneously without treatment
  • Complications
    • increased risk of urogenital infection
    • sexual dysfunction
    • low self-esteem

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