Vaginal atrophy (atrophic vaginitis) is thinning and inflammation of the vaginal walls due to a decline in estrogen. Vaginal atrophy occurs most often after menopause, but it can also develop during breast-feeding or at any other time your body's estrogen production declines.

For many women, vaginal atrophy makes intercourse painful — and if intercourse hurts, your interest in sex will naturally wane. What's more, healthy genital function is closely intertwined with healthy urinary system function.

The good news is that simple, effective treatments for vaginal atrophy are available. Reduced estrogen levels do result in changes to your body, but it doesn't mean you have to live with the discomfort and urinary problems associated with vaginal atrophy.

With moderate to severe vaginal atrophy, you may experience the following vaginal and urinary signs and symptoms:

• Vaginal dryness
• Vaginal burning
• Watery vaginal discharge
• Burning with urination
• Urgency with urination
• More urinary tract infections
• Urinary incontinence
• Light bleeding after intercourse
• Discomfort with intercourse
• Shortening and tightening of the vaginal canal

When to see a doctor
By some estimates, more than half of menopausal women experience vaginal atrophy, although very few seek treatment. The rest may resign themselves to the symptoms or be embarrassed to broach the topic with their doctors.

Make an appointment to see your doctor if you experience painful intercourse that's not resolved by using a vaginal moisturizer (Replens, others) or water-based lubricant (Astroglide, K-Y, others), or if you have vaginal symptoms, such as unusual bleeding, vaginal discharge, burning or soreness.

Vaginal atrophy is caused by a loss of estrogen. Less circulating estrogen makes your vaginal tissues thinner, drier, less elastic and more fragile.

A drop in estrogen levels and vaginal atrophy may occur:

• After menopause
• During the years leading up to menopause (perimenopause)
• During breast-feeding
• After surgical removal of both ovaries (surgical menopause)
• After pelvic radiation therapy for cancer
• After chemotherapy for cancer
• As a side effect of breast cancer hormonal treatment

Vaginal atrophy due to menopause may begin to bother you during the years leading up to menopause (perimenopause), or it may not become a problem until several years into menopause. Although the condition is common, not all menopausal women develop vaginal atrophy. Regular sexual activity helps you maintain healthy vaginal tissues.

Certain factors may contribute to vaginal atrophy. Among these are:

• Smoking. Cigarette smoking impairs blood circulation, depriving the vagina and other tissues of oxygen. Decreased blood flow to your vagina contributes to atrophic changes. Smoking also reduces the effects of naturally occurring estrogens in the body. In addition, women who smoke have an earlier menopause and are less responsive to estrogen therapy in pill form.
• Never giving birth vaginally. Researchers have observed that women who have never given birth vaginally are more prone to vaginal atrophy than are women who have had vaginal deliveries.

With vaginal atrophy, your risk of vaginal infections (vaginitis) increases. Atrophy leads to a change in the acidic environment of your vagina, making you more susceptible to infection with bacteria, yeast or other organisms.

As the lining gets thinner, you're at risk of developing open sores or cracks in the walls of your vagina. Such sores can develop from friction or injury to the vaginal walls or from recurrent vaginal infections.

Atrophic vaginal changes are also associated with changes in your urinary system and function (genitourinary atrophy), which can contribute to urinary problems. You might experience increased frequency or urgency of urination or burning with urination. Some women experience more urinary tract infections or incontinence.

Your primary care provider may refer you to a specialist (gynecologist) to evaluate your condition.

Questions your doctor may ask
Your doctor will ask questions about the symptoms you're experiencing and assess your hormonal status. Questions your doctor may ask include:

• What vaginal symptoms are you experiencing?
• How long have you experienced these symptoms?
• Do you continue to have menstrual periods?
• How much distress do your symptoms cause you?
• Are you sexually active?
• Does the condition limit your sexual activity?
• Have you been treated for cancer?
• Do you use scented soap or bubble bath?
• Do you douche or use feminine hygiene spray?
• What medications or vitamin supplements do you take?
• Have you tried any over-the-counter moisturizers or lubricants?

Diagnosis of vaginal atrophy may involve:

• A pelvic exam, during which your doctor feels (palpates) your pelvic organs and visually examines your external genitalia, vagina and cervix. During the pelvic exam, your doctor also checks for signs of pelvic organ prolapse, indicated by bulges in your vaginal walls from pelvic organs such as your uterus or bladder.
• A Pap test, which involves collecting a sample of cervical cells for microscopic examination. Your doctor may also take a sample of vaginal secretions or place a paper indicator strip in your vagina to tests its acidity.
• A urine test, which involves collecting and analyzing your urine, if you have associated urinary symptoms.

If you don't have vaginal discomfort, you might not need treatment for vaginal atrophy. Mild symptoms may be relieved by use of an over-the-counter lubricant or moisturizer. However, if you have vaginal atrophy and you're bothered by vaginal dryness, vaginal irritation, discomfort with intercourse, urinary frequency or urinary urgency, effective treatments are available.

In general, treating vaginal dryness is more effective with topical (vaginal) estrogen rather than oral estrogen. Estrogen applied to the vagina can still result in estrogen reaching your bloodstream, but the amount is minimal. Vaginal estrogen also doesn't decrease testosterone levels — important for healthy sexual function — the same way oral estrogen can.

Vaginal estrogen therapy comes in several forms:

• Vaginal estrogen cream (Estrace, Premarin, others). You insert this cream directly into your vagina with an applicator, usually at bedtime. Your doctor will let you know how much cream to use and how often to insert it, usually a daily application for the first few weeks and then two or three times a week thereafter.
• Vaginal estrogen ring (Estring). A soft, flexible ring is inserted into the upper part of the vagina by you or your doctor. The ring releases a consistent dose of estrogen while in place and needs to be replaced about every three months.
• Vaginal estrogen tablet (Vagifem). You use a disposable applicator to place a vaginal estrogen tablet in your vagina. Your doctor will let you know how often to insert the tablet; you might, for instance, use it daily for the first two weeks and then twice a week thereafter.

If vaginal dryness is associated with other symptoms of menopause, such as moderate or severe hot flashes, your doctor may suggest estrogen pills, patches, gel or a higher dose estrogen ring along with a progestin. Progestin is usually given as a pill, but combination estrogen-progestin patches also are available. Talk to your doctor to decide if hormone treatment is an option and, if so, which type is best for you.

You should experience noticeable improvements after a few weeks of estrogen therapy. Some symptoms of severe atrophy may take longer to resolve.

If you have a history of breast cancer, estrogen therapy — vaginal or otherwise — generally isn't recommended, especially if your breast cancer was hormonally sensitive.

If you're experiencing vaginal dryness or irritation, the following measures may provide some relief:

• Try a vaginal moisturizer, such as Replens or K-Y Silk-E, to restore some moisture to your vaginal area. You may have to apply the moisturizer every two to three days.
• Use a water-based lubricant, such as Astroglide or K-Y, to reduce discomfort during intercourse. Avoid petroleum jelly or other petroleum-based products for lubrication if you're also using condoms. Petroleum can break down latex condoms on contact.
• Allow time to become aroused during intercourse, and avoid intercourse if you have any vaginal irritation.

Regular sexual activity, either with or without a partner, can decrease problems with vaginal atrophy. Sexual activity enhances blood flow to your vagina, which helps keep vaginal tissues healthy.