Vulvovaginitis, Estrogen Deficient



  • 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. The duration of estrogen deficiency is a major factor in the development and severity of genitourinary syndrome of menopause.
  • 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 or antagonists, tamoxifen, danazol, medroxyprogesterone, and aromatase inhibitors
    • Elevated prolactin from hypothalamic–pituitary disorders with subsequent reduction in estrogen secretion
  • Abstinence from sexual activity appears to exacerbate atrophic changes, whereas regular sexual activity can help to preserve the vaginal epithelium, presumably by increasing blood flow and tissue elasticity.

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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