Vaginal Atrophy in Menopause: Symptoms and Treatments

Burning, dryness and discomfort during intercourse are often dismissed as inevitable consequences of aging. This is why vaginal atrophy is rarely discussed in the clinic, and almost never first brought up by the patient.

At IMAGE REGENERATIVE, in Milano and St. Moritz, regenerative gynecological treatment is proposed for this type of condition when first-line therapies are no longer sufficient or cannot be used.

Let's examine what vulvovaginal atrophy is, how to recognize it, what treatments are available today, and in which situations a regenerative approach adds value to what established therapies already offer.

What is vaginal (or vulvovaginal) atrophy

Vulvovaginal atrophy is a degenerative process of the genital tissues that depends on the reduction of circulating estrogens. Without that hormonal stimulus, the vaginal epithelium thins, glycogen production decreases, pH rises, and the lactobacillary flora becomes impoverished. The tissue loses elasticity, vascularization and the ability to lubricate, and becomes more vulnerable to microlesions and recurrent infections.

In recent years the terminology has changed. We now speak of genitourinary syndrome of menopause, a broader expression that also includes urinary symptoms, because the same estrogen receptors are present in the urethra and bladder trigone. The definition helps explain why many women consult a urologist before a gynecologist.

The most important clinical difference concerns the course. Hot flashes and sleep disorders tend to diminish over the years, while atrophy progresses if left untreated.

A systematic review published in Menopause, which collected twenty-seven studies, also notes that vaginal health is rarely discussed during visits, that knowledge of therapeutic options remains low, and that the majority of women with these symptoms report dissatisfaction with the treatment used.

Vaginal atrophy in menopause: causes and symptoms

The main cause is the estrogen decline of menopause, physiological and progressive. However, there are situations that produce the same picture at a younger age, and recognizing them avoids late diagnoses. This group includes surgical menopause after ovarian removal, oncological therapies that suppress ovarian function, prolonged use of low-dose contraceptives, and the breastfeeding phase, in which estrogen deficiency is temporary but can be very bothersome.

The symptoms with which patients present at the visit are quite recognizable:

• Persistent vaginal dryness, which does not improve with general hydration and is felt even outside of intercourse.
• Vulvar burning and itching, often attributed to an infection and treated for months with antifungals without benefit.
• Dyspareunia, that is, pain during intercourse, which appears at the beginning of penetration and progressively leads to avoiding it.
• Urinary disorders, from burning sensation during urination to urgency, up to cystitis that repeats within a few weeks.
• Tissue fragility, with minor bleeding after intercourse or after a gynecological exam.

In our team's experience, the most common reason for diagnostic delay is the interpretation of urinary symptoms as a separate problem. When instead they are read together with genital symptoms, the picture becomes coherent and the therapeutic path is considerably shortened.

Atrophic vaginitis: how to recognize it

Atrophic vaginitis is the inflammatory manifestation of atrophy, and differs from infectious vaginitis by several concrete elements. The appearance of the mucosa is pale and thinned, with visible superficial vascularization and a loss of characteristic folds. Secretions are scarce and not malodorous, contrary to what occurs in bacterial forms, and the pH measured in the clinic is high.

The diagnosis remains clinical and is based on examination, possibly integrated by vaginal pH measurement and a culture test when necessary to exclude superinfection. Complex investigations are not needed, and it is worth clarifying this to patients who arrive worried about having to face a long diagnostic process.

An element that facilitates recognition is the chronology. Symptoms develop slowly, over months, worsen continuously, and do not have the spontaneous remissions typical of infectious forms. When a woman describes discomfort lasting a year that has gradually worsened, the atrophic hypothesis is the first to consider. It remains useful to exclude vulvar dermatoses, because lichen sclerosus can overlap with atrophy and requires different management, consisting of scheduled follow-ups over time and dedicated topical therapy.

Remedies and treatments: moisturizers and hormonal therapies

The first level of intervention includes vaginal moisturizers and lubricants. These are different products, because lubricants act at the time of intercourse while moisturizers must be applied regularly to maintain mucosal trophism. They represent the most accessible and most used option, and in mild forms they may suffice.

When the condition is moderate or severe, we move to local estrogens, which remain the therapeutic reference. Administered in cream, suppositories or sustained-release rings, they act directly on the tissue with limited systemic absorption, and improve epithelial thickness, lubrication and elasticity. Their limitation is continuity, because the benefit is maintained as long as therapy continues and tends to regress upon discontinuation.

There is also a group of patients for whom estrogens, even local ones, require caution or are excluded. These are mainly women with a history of hormone-sensitive cancer, who are numerous and often live with significant symptoms without having a simple therapeutic path available. This is why non-hormonal alternatives have real clinical weight and do not represent a marginal curiosity.

Pharmacological therapies: ospemifene and suppositories

Ospemifene is a selective estrogen receptor modulator taken orally, one tablet daily with food. It acts like an estrogen on vaginal tissue without behaving like an estrogen on other target organs, and in the European Union it is authorized for the treatment of moderate to severe symptomatic vulvovaginal atrophy in postmenopausal women. It is a prescription drug, not an over-the-counter supplement.

Like any drug, it has a safety profile that must be known. The most common adverse effects include hot flashes, headache, muscle spasms, vaginal fungal infections and minor bleeding. Use is excluded in the presence of venous thrombosis, breast cancer or other estrogen-dependent tumors, unexplained vaginal bleeding and endometrial hyperplasia, conditions that must be verified before starting therapy.

Vaginal suppositories, depending on the formulation, may contain low-dose estrogens, hyaluronic acid, vitamin E or prasterone. Non-hormonal ones are useful for maintaining hydration and comfort, with a predominantly symptomatic action. The choice between different options depends on the severity of the condition, clinical history and the patient's willingness to follow continuous therapy.

Laser and regenerative treatments

Vaginal laser, in CO2 or erbium versions, produces controlled thermal damage that stimulates collagen remodeling and improved trophism. It requires multiple sessions and maintenance sessions, and its action is mainly on the superficial layers of the mucosa.

The regenerative approach starts from a different principle. Micro-fragmented autologous adipose tissue, harvested from the patient herself under local anesthesia and processed with the system patented by Prof. Carlo Tremolada, is infiltrated into the vulvovaginal tissues to provide a matrix rich in mesenchymal cells and factors that support deep regeneration. The procedure takes sixty to ninety minutes and in most cases is performed in a single session.

On the evidence level, precision is required. The study by Casarotti, Chiodera and Tremolada followed three women with postmenopausal urogenital atrophy for thirty-six months, documenting sustained symptom improvement and, in control biopsies, a recovery of glycogen production and vascularization with return to acidic pH.

It is a series of few cases with long follow-up, therefore an encouraging signal and not a large-scale proof, and patients should be presented with it for what it is.

When to consult a specialist

The simplest criterion concerns duration and impact. Discomfort that persists for more than a few weeks, that affects sexual life or sleep, or that leads to giving up daily activities, deserves a gynecological visit regardless of age. The visit also serves to distinguish atrophy from other conditions that give similar symptoms, and allows immediate initiation of the most appropriate therapy for the observed condition.

There are also situations that require prompt evaluation. These circumstances should be assessed quickly.

• Postmenopausal vaginal bleeding, which should always be investigated and never automatically attributed to atrophy.
• Recurrent cystitis that returns despite repeated courses of antibiotics.
• Intense vulvar pain, with lesions, cracks or narrowing of the vaginal entrance, a picture that may suggest lichen sclerosus.
• Discomfort appearing during or after oncological therapy, which requires a pathway built together with the oncologist.

In our team's experience, the most common error remains prolonged self-treatment with over-the-counter products, which delays diagnosis by months. Atrophy responds well when properly identified, and the right time to identify it is the first moment it truly disturbs daily life.

Frequently asked questions

Can vaginal atrophy be treated without hormones?

Yes. Non-hormonal vaginal moisturizers, hyaluronic acid suppositories, laser and autologous adipose tissue treatment are all paths that do not involve estrogen administration. This possibility is particularly relevant for women with a history of hormone-sensitive cancer, for whom estrogen therapy requires caution or is excluded.

How long do the results last?

It depends on the chosen option. Moisturizers and local estrogens maintain the benefit as long as they are used regularly, laser requires periodic maintenance sessions, while regenerative treatment with adipose tissue aims for a more prolonged effect over time, documented in a small case series up to thirty-six months. The initial evaluation also serves to establish what timeframe is realistic.

Does vaginal atrophy worsen over time?

It tends to progress if left untreated, and in this it differs from other menopausal symptoms that spontaneously diminish. This is why it is advisable to intervene early: tissues respond better when the process is less advanced and quality of life has not already adapted to the discomfort.

After breast cancer, can something be done?

Yes, and it should be done in agreement with the treating oncologist. Non-hormonal options remain available, from vaginal moisturizers to laser to autologous adipose tissue treatment, which does not introduce hormones into the body. Joint evaluation allows choosing the path compatible with ongoing oncological therapy.

Content reviewed by the medical-scientific committee of IMAGE REGENERATIVE. The information provided is for informational purposes and does not replace specialist consultation.