Menopause & perimenopause

Conditions commonly associated with vaginal dryness

by Marcy Holmes, NP, Certified Menopause Clinician

There are many instances where a woman’s vaginal dryness or similar discomfort could be a sign of an associated condition needing attention and possible treatment.

Vaginal dryness is a delicate subject for sure, which is why we always encourage women to seek evaluation with a gynecologist or women’s health practitioner rather than a general practitioner, as these providers have greater training and clinical experience in conditions associated with vaginal dryness. If you are in menopause, a gynecologic healthcare provider specializing in menopause is often an ideal choice. Conventional doctors and other general providers could possibly miss lichen sclerosis, for example, or be at a loss for what to do with vulvodynia at all.

We’ll review a few of the conditions associated with vaginal dryness and how related problems can arise. If you notice changes that fit the descriptions for these conditions below, be sure to schedule an appointment as soon as possible. If your symptoms match those for vulvodynia or lichen sclerosis, you may want to directly pursue a vulvar dermatology specialist if you can find one in your region.

Atrophic vaginal changes

Atrophic vaginal changes can often cause vaginal dryness in older women who have declining estrogen levels, but younger women can also be affected by atrophic changes. For example, vaginal dryness that stems from atrophic vaginal changes is not unusual in women with anorexia, women who have recently given birth, and women who have recently lost a significant amount of weight.

This is a condition where the tissues in and around your vagina tend to flatten out and become somewhat smoother, thinner, and paler in appearance. These tissues may be undergoing a process known as atrophy, a term that simply means “loss of nourishment.”

We can identify the low-estrogen features of these cells by simply looking at the tissues. Under a microscope, atrophic vaginal cells take on a thin appearance from lower estrogen, as opposed to the plump, well-estrogenized appearance of normal vaginal cells.

Atrophic vaginal changes occur when there are low levels of estrogen and a lower than normal volume of secretions, but are not typically associated with inflammation or irritation — just dryness. Along with nutritional measures that support hormonal balance, women with atrophic vaginal changes can choose either topical estrogen treatments or try nonprescription lubricating and moisturizing remedies.

Atrophic vaginitis

Atrophic vaginitis produces atrophic vaginal changes similar to those just described, but in addition to a smooth, flat appearance in the vaginal tissue, there is also marked inflammation, redness and discomfort — thus the ‘-itis’ descriptor, which indicates inflammation. In addition to vaginal dryness, the symptoms that frequently accompany atrophic vaginitis can include burning, itching, painful sex (dyspareunia), and even discomfort with urination since the urethra can also be affected (atrophic urethritis).

Because estrogen is involved in maintaining a normal vaginal ecology, a decrease in estrogen levels can sometimes lead to changes in the pH of the vagina and the normal vaginal flora. Some women suffering from atrophic vaginitis can have vaginal odor associated with an overabundance of bacteria that thrive in a higher-pH, estrogen-deficient vagina. These bacteria can exacerbate the inflammation and itchiness, and there may be a thin, greenish discharge if the vaginal tissue develops cracks or sores and the cells attempt to heal.

We typically prescribe a topical bioidentical estrogen for immediate use by our patients with atrophic vaginitis. Some women will also require an antibiotic to reduce any vaginal bacteria present. If a woman’s atrophic vaginitis persists, she may need to use a vaginal estrogen product on a regular basis for relief. We always encourage women to insist upon bioidentical estrogen products that contain estriol (E3) or estradiol (E2), rather than Premarin Vaginal Cream, which is not bioidentical. (For more details, see our page on products for vaginal dryness relief.)

Genital lichen sclerosis

Genital lichen sclerosis (sometimes spelled lichen sclerosus) is an autoimmune skin disorder that can affect both men and women of all ages, but especially occurs in postmenopausal women. It generally starts as small, smooth white patches (hypopigmentation) that appear in a symmetrical pattern on the vulva. These may extend forward to the perineum and posteriorly to the anus. Over time, lichen sclerosis can grow into larger patches as the skin becomes thinner and somewhat crinkled, like parchment paper.

For some women, an early sign is itching, for others it is dryness. Women with milder cases of lichen sclerosis may notice no symptoms at all, and even more advanced cases may cause only an annoying itch. Unfortunately, the rubbing and scratching that relieve the itch lead to torn, bleeding tissue, and painful sores. If lichen sclerosis develops around the anus, rectal discomfort and itching may result.

If the issue is left untreated, the normal tissue folds may lose their architecture over time and almost “melt” away. Women can also lose the “details” and sensation of the clitoris. Tightening and scarring may occur to traumatized areas, and the vaginal opening can narrow significantly.

As is true of many autoimmune disorders, the exact cause of lichen sclerosis is uncertain. In more advanced cases, a doctor should be able to diagnose it readily by visual exam, but early or milder cases may require a small punch biopsy for accurate diagnosis. Mild cases can be watched closely, but treatment is usually warranted as lichen sclerosis can lead to tissue scarring and damaged function.

Previously doctors gave topical testosterone to women with lichen sclerosis, but we now know that the most effective treatment is a topical corticosteroid, such as Temovate, Valisone, or Ultravate. Usually women will benefit from a bioidentical estrogen vaginal product as well, if they are menopausal. Most women respond very well to treatment and gain relief from the itching and discomfort, but early detection and intervention are key. Once there is pronounced scarring or tissue obliteration, it’s hard to reverse.

Some mild cases of lichen sclerosis may respond well to a topical zinc cream applied daily. I had one menopausal woman choose this method rather than the prescription products due to finances. She used it daily, and year after year I was amazed by how the condition remained almost invisible.

Vulvodynia

Vulvodynia (sometimes misspelled vulvadynia) is a term to describe a set of conditions where there is otherwise no clear explanation for chronic burning, itching, and/or pinpoint pain of the vulva, which can radiate to the anus or down the thighs. Vulvar pain and discomfort can occasionally accompany vaginal dryness and even linger on once the dryness has been addressed. Vulvodynia is often accompanied by sexual difficulties and can also result in psychological suffering. While this condition is most common in women of childbearing age, it can cause lifelong discomfort and distress for many women.

No one knows for sure what causes vulvodynia, but most doctors believe it develops from a combination of stressful factors. These may include allergies or sensitivities (including food-related intolerances and other GI issues), yeast infections (candidiasis), external irritants like soap, inflamed nerves, bacterial infection, or autoimmune dysfunction. If a woman has a GI concern, such as dysbiosis, it will need to be addressed prior to resolving the vulvodynia.

Vulvodynia may also involve unresolved emotional issues. Some women may be embarrassed by this problem and may avoid sexual relations or a discussion of the problem with their healthcare providers. It’s unfortunate that so many physicians continue to have a poor understanding of how common this problem is, and how it can benefit from both medical and behavioral interventions. Treating vaginal dryness in women with vulvodynia is just part of the solution, and behavioral therapies have been found to be quite helpful in some cases.

Fortunately, there are increasing efforts being made to raise awareness of vulvodynia. The National Vulvodynia Association is an organization dedicated to educating the healthcare profession and the public regarding the prevalence of this condition and to providing support to women suffering from vulvodynia.

Other issues associated with vaginal dryness

There are many other health conditions that can exacerbate vaginal dryness. These include bacterial vaginosis, herpes, Candida, psoriasis, contact dermatitis, and condylomata (genital warts), just to name a few.

Again, we encourage you to see a women’s healthcare provider on a regular basis to maintain gynecologic health, and to seek additional care as needed to screen for any conditions that may be underlying vaginal dryness, itching, pain, or other symptoms of discomfort.

• For more information on the many factors that come into play with vaginal dryness and discomfort, see our full article on vaginal dryness.


• See also our charts of prescription and over-the-counter products for information on natural and bioidentical treatments for vaginal dryness.

Related to this article:

References & further reading on conditions associated with vaginal dryness

 

Original Publication Date: 07/02/2007
Last Modified: 02/16/2010
Principal Author: Marcy Holmes, Certified Menopause Clinician