Vulvovaginitis, Estrogen Deficient

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  • Estrogen-deficient vulvovaginitis is a hypoestrogenic state with external genital, urologic, and sexual sequelae.
  • Estrogen deficiency affects all tissues in the female body; however, the genital tissues are especially hormone responsive and are most affected.
  • Decreased estrogen leads to decreased blood flow to vaginal tissues and thinning of vaginal tissues, dryness, and atrophy. Patients with estrogen-deficient vulvovaginitis may present with urinary incontinence, vaginal burning and itching, dyspareunia, increased urinary frequency, recurrent UTIs, or various other symptoms.
  • This condition is also referred to as genitourinary syndrome of menopause when associated with the postmenopausal state, although this condition may occur in women of all ages.
  • System(s) affected: reproductive


Predominant age: postmenopausal females. The average age of menopause in the United States is 51.3 years but ranges from 45 to 55 years old.

  • Approximately 40–54% of postmenopausal women are affected.
  • Approximately 15% of premenopausal women are also affected.
  • This condition is likely underdiagnosed because patients may be reluctant to report symptoms because of embarrassment or the misconception that symptoms should be accepted as a natural part of aging (1).

Etiology and Pathophysiology

  • Estrogen is vasoactive, increasing blood flow to target tissues, lubrication, and elasticity.
  • Decreased estrogen levels in the vagina and vulva result in decreased blood flow and decreased lubrication and elasticity of vaginal and vulvar tissues as well as thinning of these tissues.
  • Decreased cellular maturation results in decreased glycogen stores, which affects the normal vaginal flora and consequently the pH.
  • The resulting increased pH impairs the viability of the normal flora, permitting the proliferation of fecal and other flora, resulting in UTIs and vaginal infections (1)[C].
  • Estrogen deficiency is caused by the following:
    • Menopause (surgical or natural)
    • Premature ovarian failure (chemotherapy, radiation, autoimmune, anorexia, genetic)
    • Postpartum estrogen deficiency in lactating women
    • Medications that alter hormonal concentration, such as gonadotropin-releasing hormone agonists, tamoxifen, danazol, medroxyprogesterone, and aromatase inhibitors
    • Elevated prolactin from hypothalamic–pituitary disorders

No known pattern

Risk Factors

  • Estrogen-deficient states, including lactation
  • Smoking
  • Alcohol abuse
  • Sexual abstinence or decreased frequency of coital activity
  • Lack of exercise
  • Absence of vaginal childbirth
  • Chemotherapy
  • Radiation therapy

Commonly Associated Conditions

  • Urge and stress urinary incontinence
  • Pelvic organ prolapse
  • Frequent UTIs
  • Bacterial or fungal vulvovaginitis
  • Vaginal stenosis
  • Loss of libido
  • Dyspareunia

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