QuestionSBA
QuestionChoice
As this patient does not present with post menopausal bleeding she does not require a 2 week wait referral.
62225
c
Two week wait referral for endometrial cancer
QuestionChoice
Whilst chemical irritants found in some washing poweders, soaps, panty liners or condoms may cause vulva or vaginal irritation which could present with similar symptoms, atrophic vaginitis is the most likely cause given the patient's age. Therefore, these may be helpful changes to make but topical oestrogen would be the first-line choice.
62226
d
Recommend changing washing powder and soap
QuestionChoice
Whilst systemic HRT would be helpful in treating atrophic vaginitis due to the affects of oestrogen, it is not first line treatment to those presenting solely with atrophic vaginitis. It would be appropriate if the patient presents with other menopausal symptoms. 10-25% of those recieving HRT will still have symptoms of atrophic vaginitis which require additional topical oestrogen.
62227
e
Systemic hormone replacement therapy (HRT)
QuestionChoice
The history is more suggestive of atrophic vaginitis rather than a UTI. However, having atrophic vaginitis can predispose to UTIs, therefore it is important to screen for symptoms of one such as dysuria or increased urinary frequency.
62224
b
Antibiotics for a urinary tract infection (UTI)
QuestionChoice
Atrophic vaginitis is caused by a fall in oestrogen, it is therefore most common in post-menopausal people. Common symptoms include vaginal dryness, pain and itching. It can also cause urinary symptoms and UTIs. Topical oestrogen is a first line treatment option.
62223
a
Topical oestrogen
Concept
Chapter
# Summary
  
 
Atrophic vaginitis, also known as vulvovaginal atrophy, is a condition characterised by inflammation and thinning of genital tissues due to reduced oestrogen levels, most commonly seen after menopause. Key signs and symptoms include thinning of vaginal mucosa, loss of pubic hair, narrowed introitus, and vaginal dryness, among others. Key investigations include clinical examination, transvaginal ultrasound, endometrial biopsy if required, and an infection screen. Management strategies primarily involve hormonal treatments, non-hormonal treatments, and in some cases, transvaginal laser therapy.
  
 
# Definition
  
 
Atrophic vaginitis, also known as vulvovaginal atrophy, is characterised by inflammation and thinning of the genital tissues due to a decrease in oestrogen levels. This condition is most common after menopause.
  
 
  

# Aetiology
  
 
The primary cause of atrophic vaginitis is a decline in oestrogen levels, which typically occurs post-menopause.
  
 
# Signs and Symptoms
 
 
  - Thinning of the vaginal mucosa
  - Loss of pubic hair
  - Narrowed introitus
  - Loss of vaginal rugae (folds)
  - Vaginal dryness and itching
  - Dyspareunia
  - Post-coital bleeding
  - Vaginal discharge from inflammation
  - Urinary symptoms such as dysuria and recurrent UTI
  
 
# Differential Diagnosis
  
 
- **Endometrial cancer and endometrial hyperplasia:** presents with post-menopausal bleeding. Ruled out with transvaginal USS and possible biopsy.
- **Sexually transmitted infection:** presents with itching and abnormal discharge. Would have cervical tenderness on bimanual examination and can be diagnosed using vaginal swabs. 
- **Lichen planus:** can cause itchiness and dyspareunia. Would present with pale, dry patches which may be cracked and cause bleeding. 
- **Vaginismus:** also presents with dyspareunia but would not show signs of atrophy on speculum examination. 

  
 
# Investigations
  
 **Bedside:**
 
* Clinical examination, including speculum examination if tolerated, to look for vaginal signs of atrophy. This is usually enough for diagnosis. 
* Vaginal swabs for infection screening if itching of discharge is present.  
 
No bloods, imaging or invasive tests are required. 
  

# Management
  
 
Hormonal treatment:
  
  - Topical oestrogen preparations
  - Systemic hormone-replacement therapy (oral or transdermal)

  
Non-hormonal treatments:

  - Lubricants, which provide short-term improvement to vaginal dryness, alleviating symptoms such as dyspareunia
  - Moisturisers, which should be used regularly

  
 
# References
  
 
  [Patient Info](https://patient.info/doctor/atrophic-vaginitis)
935
986
Atrophic vaginitis
Topic
26
Gynaecology
12506
A 68 year old female attends her GP practice with symptoms of vaginal dryness associated with itching.
On speculum examination it is noted that the vaginal skin is thin.

Which of the following is the best next step in the management of this patient?
a