Vulvar atrophy is a common condition resulting from hormonal changes, primarily the decrease in estrogen that occurs with aging. This process causes the tissues of the vulva and vagina to become thinner, drier, and less elastic over time. Affecting approximately 50% of women after menopause, seeking appropriate care can significantly alleviate symptoms.
Understanding the Underlying Cause
The physiological root of vulvar atrophy is the body’s diminished production of estrogen, which typically occurs during menopause. Estrogen is a trophic hormone necessary for maintaining the health, thickness, and vascularity of the genital and lower urinary tract tissues. This deficiency causes biological changes in the vulva, vagina, urethra, and bladder, all of which are rich in estrogen receptors.
This hormonal deficiency reduces blood flow, causing the loss of collagen and hyaluronic acid, components that provide plumpness and moisture. The epithelium, the vaginal lining, loses its protective layers, resulting in thinning and increased fragility. Because this condition affects both the genital and urinary systems, medical professionals often use the more comprehensive term, Genitourinary Syndrome of Menopause (GSM).
Visible Changes to the Vulva and Vagina
The physical manifestation of vulvar atrophy is directly tied to the tissue changes. The tissues of the vulva and vaginal lining often exhibit a noticeable change in color, becoming pallid or paler than their previous pink hue. This reduced pigmentation is due to decreased blood flow, or vascularity, in the area.
The external genitalia, particularly the labia minora and labia majora, may appear smaller and flatter due to the loss of underlying fat and elasticity (resorption). The skin texture changes from plump to smooth and shiny, sometimes resembling thin parchment paper. Within the vaginal canal, the characteristic folds (rugae) flatten out and disappear, resulting in a smooth, less distensible vaginal wall.
In advanced cases, the vaginal opening, or introitus, may constrict and narrow because of the loss of tissue pliability and resilience. This loss of elasticity can make the tissue more susceptible to minor trauma, sometimes resulting in small tears or fissures upon stretching, such as during a physical examination or sexual activity. The vulvar skin can also show a loss of pubic hair and a reduction in the prominence of the clitoral hood.
Accompanying Sensations and Functional Symptoms
Vulvar atrophy is characterized by uncomfortable sensations and functional issues resulting from the fragile, thinned tissues. The most common complaint is persistent vaginal dryness, often causing general daily discomfort. This dryness is a direct result of decreased natural lubrication and reduced vaginal secretions.
Irritation, burning, and itching (pruritus) are frequent symptoms caused by the delicate tissue being easily irritated and inflamed. Because the vaginal lining is thinner and less resilient, sexual intercourse frequently becomes painful, a symptom called dyspareunia. The fragile tissue can also bleed easily with minimal friction, sometimes resulting in post-coital spotting.
The hormonal changes also affect the lower urinary tract, leading to symptoms like increased urinary frequency and urgency. The thinning of the urethral lining and the change in vaginal pH (becoming less acidic and more alkaline) can lead to recurrent urinary tract infections. These urinary symptoms are linked to the atrophy of the surrounding tissues and are part of the Genitourinary Syndrome of Menopause.
Approaches to Management
Management focuses on reversing tissue changes and alleviating symptoms through hormonal and non-hormonal strategies. The most effective treatment is often low-dose topical estrogen therapy, available as creams, vaginal tablets, or rings. These treatments deliver estrogen directly to the affected tissues, restoring thickness, elasticity, and blood flow while minimizing systemic absorption.
Non-hormonal options are used for milder symptoms or by those who cannot use hormone therapy, such as breast cancer survivors.
Non-Hormonal Options
- Vaginal moisturizers are designed for regular use to restore moisture and provide longer-lasting relief from dryness.
- Water- or silicone-based lubricants are applied immediately before sexual activity to reduce friction and pain.
Simple lifestyle adjustments can also help manage the condition by reducing irritation. Avoiding harsh soaps, scented hygiene products, and tight-fitting clothing prevents unnecessary friction and chemical irritation of the delicate vulvar skin. Regular sexual activity is beneficial, as it naturally increases blood flow to the area, which helps maintain tissue elasticity and health.