Atrophic Vaginitis (Genitourinary Syndrome of Menopause)

Why it happens

Estrogen keeps the vaginal lining thick, elastic, moist and acidic. It supports blood flow and the protective lactobacilli bacteria. When estrogen falls:

• the lining thins and becomes pale, dry and easily torn
• natural lubrication during arousal decreases
• the vagina becomes shorter and narrower and less stretchy
• vaginal pH rises, so lactobacilli decline and infections become more likely
• the urethra and bladder base, which also respond to estrogen, become more sensitive

Causes of low estrogen

• natural menopause, the most common cause
• surgical removal of both ovaries
• breastfeeding
• medicines that block estrogen: aromatase inhibitors for breast cancer, GnRH analogues
• chemotherapy or pelvic radiation
• smoking, which lowers estrogen effects

Symptoms

Vaginal and vulvar

• vaginal dryness
• burning, irritation and itching
• pain during intercourse (dyspareunia) and reduced arousal
• light bleeding or spotting after sex
• thin, watery or yellowish discharge
• discomfort with tight clothing, exercise or wiping

Urinary

• burning on urination
• urgency and frequency
• recurrent urinary tract infections
• urge incontinence

Symptoms often appear several years after the last period and gradually worsen. Many people do not mention them to their doctor, though effective treatment is available.

Diagnosis

A clinician makes the diagnosis from symptoms and a pelvic exam, which shows pale, thin, dry tissue with fewer folds, and sometimes redness or small bleeding spots. Tests may include:

• vaginal pH, typically above 4.5
• swabs and microscopy to rule out yeast, bacterial vaginosis or trichomoniasis
• urine culture for urinary symptoms
• assessment of any postmenopausal bleeding with ultrasound or biopsy

Other conditions with similar symptoms include lichen sclerosus, contact dermatitis, infections and vulvar skin conditions.

Treatment

Non-hormonal options

• Vaginal moisturizers: used 2 to 3 times a week regardless of sexual activity. They restore moisture and comfort.
• Lubricants: water- or silicone-based, used during sex. Avoid products with fragrance, warming agents or glycerin if they irritate.
• Regular sexual activity or vaginal dilators: maintain blood flow and elasticity.
• Pelvic floor physical therapy: helps pain with sex and urinary symptoms.
• Avoid irritants: scented soaps, douches and wipes.

Low-dose vaginal estrogen

The most effective treatment for moderate to severe symptoms. Available as creams, tablets or inserts, and a flexible ring changed every 3 months. It restores tissue thickness, moisture and acidity, eases pain with sex, and reduces urinary urgency and recurrent UTIs. Improvement starts in a few weeks, with full effect in 2 to 3 months.

Because only tiny amounts enter the bloodstream, vaginal estrogen does not carry the risks of systemic hormone therapy, and a progestogen is not needed to protect the uterus. In late 2025 the FDA announced it would remove the boxed warning from menopausal hormone therapy labels, including vaginal estrogen. People with a history of breast cancer should discuss it with their oncologist. It is often still an option, especially for those not taking aromatase inhibitors.

Other prescription options

• Vaginal DHEA (prasterone): an insert converted to estrogen and androgens within the vaginal cells.
• Ospemifene: a daily tablet that acts like estrogen on vaginal tissue.
• Systemic hormone therapy: treats hot flashes too, but some people still need added vaginal estrogen.

Laser and radiofrequency treatments are marketed for vaginal atrophy, but evidence is limited and the FDA has warned against unproven claims.

Complications

Without treatment, symptoms tend to worsen, leading to recurrent UTIs, painful sex and avoidance of intimacy, tearing and bleeding, narrowing of the vagina, and reduced quality of life.

Frequently asked questions

What are the symptoms of atrophic vaginitis?

The main symptoms are vaginal dryness, burning and itching, pain during sex, spotting after intercourse, thin discharge, and urinary symptoms such as burning, urgency and frequent infections. They usually start a few years after menopause and gradually get worse without treatment.

Is vaginal estrogen safe?

For most people, low-dose vaginal estrogen is very safe because little is absorbed into the bloodstream. It does not appear to raise the risk of blood clots, stroke or breast cancer in studies. People with a history of hormone-sensitive cancer should discuss options with their oncologist.

Can atrophic vaginitis be cured?

It is a chronic condition caused by low estrogen, so symptoms usually return if treatment stops. With ongoing moisturizers or vaginal estrogen, most people have excellent symptom control and comfortable sex.

Is atrophic vaginitis the same as vaginal atrophy?

Yes. Atrophic vaginitis, vaginal atrophy, vulvovaginal atrophy and genitourinary syndrome of menopause all describe the same estrogen-related changes. The newer term GSM includes the urinary symptoms that often occur with it.

Can young women get atrophic vaginitis?

Yes. It can occur during breastfeeding, after removal of the ovaries, with some contraceptives in rare cases, and with treatments that block estrogen, such as those for breast cancer or endometriosis. Breastfeeding-related dryness usually resolves when periods return.