Vaginal atrophy

Vaginal atrophy (also known as genitourinary syndrome of menopause, GSM – genitourinary syndrome of menopause) is a chronic condition resulting from estrogen deficiency, leading to gradual thinning, dryness, and loss of elasticity of the vaginal epithelium as well as the tissues of the vulva and lower urinary tract. This phenomenon primarily affects menopausal and postmenopausal women, however, it can also occur in other situations of hypoestrogenism. The changes are progressive and affect both the comfort of daily life, as well as sexual functions and the urinary system. Vaginal atrophy represents a significant clinical problem, often underdiagnosed despite its high prevalence.

Vaginal atrophy – what it is

Vaginal atrophy is a degenerative process involving the vaginal mucosa and adjacent anatomical structures, directly related to the decrease in estrogen levels. Estrogens are responsible for maintaining the proper thickness of the stratified squamous epithelium, its blood supply, hydration, and the presence of glycogen, which conditions the normal bacterial microflora (the dominance of Lactobacillus lactic acid bacteria).

In the course of atrophy, the following occur:

thinning of the vaginal epithelium,
a decrease in the number of superficial cells,
a decrease in mucus production,
an increase in vaginal pH (loss of acidic environment),
a decrease in tissue elasticity and blood supply.

The consequence of these changes is an increased susceptibility to micro-injuries, infections, and chronic inflammation. The process involves not only the vagina but also the vulva, urethra, and bladder, which explains the coexistence of urogenital symptoms.

Vaginal atrophy – causes

The main cause of vaginal atrophy is estrogen deficiency, however, its etiology can be diverse. Most often, this condition develops during menopause, when the physiological cessation of ovarian function occurs.

The most important causes include:

natural menopause – the most common cause, related to age,
induced menopause (iatrogenic), e.g., after:
- removal of the ovaries (ovariectomy),
- chemotherapy or radiotherapy,
lactation period – a temporary decrease in estrogens,
use of anti-estrogenic drugs, e.g., in breast cancer therapy,
hormonal disorders (e.g., ovarian failure),
chronic stress and malnutrition – impact on the hypothalamus–pituitary–ovarian axis.

An important factor exacerbating symptoms is also the lack of sexual activity, which promotes reduced blood supply and tissue elasticity. Additionally, mechanical factors, such as childbirth injuries or chronic inflammation, can accelerate atrophic processes.

Vaginal atrophy – symptoms

Symptoms of vaginal atrophy are chronic and progressive, and their severity can significantly reduce the quality of life. In clinical practice, local symptoms (vaginal and vulvar) and urinary tract symptoms are distinguished.

The most common symptoms are:

Vaginal and vulvar symptoms:

vaginal dryness,
burning and itching sensation,
discomfort or pain during intercourse (dyspareunia),
contact bleeding (e.g., after intercourse),
increased susceptibility to irritation.

Urological symptoms:

urinary frequency,
urinary urgency,
recurrent urinary tract infections,
discomfort during micturition.

At the histological level, atrophy of the superficial layer of the epithelium, a decrease in the number of collagen and elastin fibers, and deterioration of microcirculation are observed. As a result, there is a loss of elasticity and regenerative capacity of the tissues.

Vaginal atrophy – when to see a specialist

A specialist consultation (gynecological or urogynecological) is indicated in every case of persistent symptoms suggesting vaginal atrophy, especially if they affect daily functioning or sexual life.

Key indications include:

chronic vaginal dryness and discomfort,
pain during intercourse,
recurrent intimate infections or urinary tract infections,
contact bleeding,
lower urinary tract symptoms without a discernible infectious cause.

Diagnostics include a gynecological examination, assessment of vaginal pH, and – in justified cases – cytological or microbiological tests.

The contemporary therapeutic approach is multidirectional and includes:

local hormone therapy (vaginal estrogens),
moisturizing and regenerating preparations,
urogynecological physiotherapy,
modern tissue stimulation methods, such as:
- fractional laser therapy,
- microneedling radiofrequency.

These methods lead to improvement in tissue trophics, increased blood supply and elasticity, and restoration of the epithelium. Early implementation of treatment allows for inhibiting the progression of changes and significantly improving the patient's quality of life.