Atrophic Vaginitis and Urinary Symptoms

Overview

Atrophic vaginitis, now clinically referred to as Genitourinary Syndrome of Menopause (GSM), describes the changes affecting the vagina, vulva, and urinary tract when estrogen levels decline after menopause. Unlike vasomotor symptoms such as hot flushes that often improve over time, GSM progressively worsens without treatment.

The newer term GSM reflects the condition’s dual impact on both genital and urinary systems. Women experience not only vaginal dryness and discomfort but also significant urinary symptoms including painful urination, recurrent UTIs, and incontinence.

GSM affects 50-70% of postmenopausal women, with symptoms typically emerging 4-5 years after menopause. Despite its prevalence, the condition remains underdiagnosed and undertreated. Many women feel too embarrassed to discuss their symptoms, and only about 25% seek medical help.

Symptoms

Urinary Symptoms

Recurrent urinary tract infections represent the most common urinary manifestation of GSM. Women may experience three or more UTIs per year due to the loss of protective vaginal bacteria, which allows harmful bacteria to colonize the vagina and subsequently infect the bladder.

Dysuria, or painful urination, frequently occurs as a burning or stinging sensation. This symptom is often mistaken for a UTI even when no infection is present, resulting from thin, sensitive urethral tissue rather than bacterial invasion.

Urinary urgency and frequency cause sudden, strong urges to urinate and the need to void frequently throughout the day. These symptoms overlap significantly with overactive bladder, and many women have both conditions simultaneously.

Stress urinary incontinence develops when weakened urethral support causes leakage during coughing, sneezing, or exercise. The loss of tissue bulk around the urethra contributes to this problem.

Vaginal and Vulvar Symptoms

Vaginal dryness is the most common complaint, often accompanied by thin, watery discharge, itching, and irritation. Many women experience bleeding after intercourse and painful intercourse (dyspareunia), which can significantly impact relationships and quality of life.

Vulvar symptoms include dryness, itching, burning sensations, and general soreness. In severe cases, fusion of the labia minora may occur.

Causes

The vagina, urethra, and bladder all contain estrogen receptors. Estrogen maintains tissue thickness and elasticity, promotes blood flow, supports protective lactobacilli (beneficial bacteria), preserves acidic vaginal pH, ensures proper urethral and bladder function, and maintains pelvic floor muscle tone.

When estrogen declines at menopause, tissues become thin, dry, and fragile. Blood flow decreases, protective bacteria die off, and vaginal pH rises to become less acidic. This environmental shift allows harmful bacteria to thrive and leaves tissues vulnerable to irritation and injury.

Several factors can trigger GSM. Natural menopause causes gradual estrogen decline. Surgical menopause from removal of both ovaries produces abrupt estrogen loss. Breast cancer treatments, chemotherapy, and premature ovarian insufficiency can all precipitate early or severe GSM.

UTIs become more frequent for several interconnected reasons. Changes in vaginal pH create a less acidic environment where harmful bacteria flourish. Loss of lactobacilli removes natural protection against E. coli colonization. Thinner tissues are more susceptible to infection. Incomplete bladder emptying leaves residual urine that promotes bacterial growth. Sexual activity causes greater trauma to fragile tissues.

Diagnosis

Healthcare providers typically diagnose GSM based on symptoms and physical examination rather than laboratory tests.

A thorough history includes menopausal status, timing and severity of symptoms, impact on quality of life and relationships, previous treatments attempted, and pattern of recurrent infections.

Physical examination reveals characteristic findings: pale, thin vaginal tissue; loss of vaginal rugae (natural folds); narrowing of the vaginal opening; petechiae (tiny bleeding spots); loss of labial fat pads; and changes to the urethra.

Testing, when performed, may include vaginal pH measurement. Healthy premenopausal vaginal pH ranges from 3.5 to 4.5 (acidic), while postmenopausal pH typically exceeds 5.0. A vaginal maturation index examines cells microscopically to assess the proportion of mature superficial cells, with decreased numbers indicating atrophy. Urine tests help when UTI is suspected and may show sterile pyuria (white blood cells without infection).

Treatment

Vaginal Estrogen

Low-dose vaginal estrogen remains the gold standard treatment. Available forms include vaginal cream applied two to three times weekly, vaginal tablets inserted twice weekly, and a vaginal ring replaced every three months.

Vaginal estrogen works by restoring tissue thickness and elasticity, returning vaginal pH to healthy acidic levels, repopulating protective lactobacilli, improving blood flow, and strengthening urethral tissue.

Safety data supports vaginal estrogen use in most women. Systemic absorption remains very low, and the treatment is generally safe even for breast cancer survivors with oncologist guidance. Minimal systemic effects occur, and long-term use is appropriate.

Improvement typically begins within 2-4 weeks, with full benefit achieved by 12 weeks. Symptoms return if treatment stops, so most women require indefinite therapy. Vaginal estrogen reduces recurrent UTIs by approximately 50%, improves urgency and frequency, and helps stress incontinence.

Non-Hormonal Options

Vaginal moisturizers applied two to three times weekly provide longer-lasting hydration than lubricants. Hyaluronic acid products have become popular choices.

Lubricants used during sexual activity provide comfort but do not treat the underlying condition. Water-based or silicone-based formulations are available.

Ospemifene (Osphena) is an oral selective estrogen receptor modulator (SERM) that helps vaginal tissue without stimulating the uterus. This medication offers an alternative when vaginal estrogen is unsuitable.

Laser and radiofrequency treatments represent emerging therapies that stimulate collagen production. Evidence continues to develop, and these treatments remain expensive and not widely available, requiring multiple sessions.

Additional Urinary Measures

Beyond vaginal estrogen, maintaining adequate fluid intake, urinating after intercourse, and avoiding bladder irritants can help manage urinary symptoms. Some women find benefit from cranberry products or D-mannose supplements.

When to See a Doctor

Seek medical evaluation for recurrent UTIs (three or more per year), persistent painful urination, painful intercourse affecting your relationship, any bleeding after menopause, or symptoms significantly impacting your quality of life.

GSM will not improve without treatment. Healthcare providers evaluate these symptoms routinely and can offer effective treatments. Women with breast cancer should discuss options with their oncology team, as non-hormonal alternatives exist and low-dose vaginal estrogen may be appropriate in many cases.

Women taking systemic hormone replacement therapy (HRT) may still develop GSM symptoms, as systemic treatment does not always prevent local tissue changes. Additional vaginal estrogen may be needed.