Every 7 seconds, another baby boomer turns 50— that is, more than 12,000 people each day.1 With an average life expectancy of almost 80 years, women now spend one third of their lives after menopause.2 These women continue to lead active lives, and maintaining a high quality of life—including the successful management of menopausal symptoms—is important to them. Because of the heightened awareness among patients and providers regarding the potential adverse effects of hormone replacement therapy (HRT), many older women choose to minimize their use of this therapy or find alternative treatments. Clinicians should be familiar with available treatment options and be prepared to evaluate each patient to determine appropriate therapy.
Menopause symptoms
Declining levels of estrogen and rising levels of follicle-stimulating hormone (FSH) herald the onset of menopause. Although a number of symptoms have been associated with the transition to menopause, only vasomotor and urogenital symptoms have been shown to be directly correlated with these changing hormone levels. 3 Typical vasomotor symptoms are hot flashes and night sweats, while reported urogenital symptoms include vaginal dryness, itching, dyspareunia, urinary frequency, and urinary tract infections (UTIs) (see Table 1). Although the onset of symptoms and their severity are unique to each woman, vasomotor symptoms often occur earlier in the menopausal transition and may wane after a number of years. Urogenital symptoms may occur at any time but often become more bothersome later in the menopausal phase and continue into the later years.3,4
Prevalence
Several studies designed to characterize menopausal symptoms have found that approximately 30% to 40% of 
women experience urogenital symptoms, with the most commonly reported being vaginal dryness and dyspareunia.3,5-8 One study found that 47% of women complained of vaginal dryness 3 years after menopause, compared with 25% only 1 year after menopause. In fact, the researchers noted that “vaginal dryness was the only symptom that appeared to increase exponentially with time from the late perimenopause.”3 According to a similar study, 28% of women experienced vaginal symptoms at menopause, increasing to 46% of women 9 years later.5 The same group also showed increasing urinary frequency and stress incon tinence, with 32% reporting these conditions at menopause compared with 59% 9 years later.5
Despite the prevalence of urogenital symptoms, only 25% of these women seek medical treatment.7,9 Clinicians often do not screen for urogenital symptoms, and many women simply assume they are an irreversible part of aging. Oral HRT has been used universally for menopausal symptom treatment and may still be the best option for women with multiple symptoms and no contraindications to HRT. However, the premature cessation of the estrogen-plus-progestin arm of the Women's Health Initiative trial has led many patients and clinicians to avoid long-term use of oral hormone therapy, regardless of how well they comprehend the risks and benefits of treatment.10,11 In addition, 10% to 40% of women already taking oral estrogen still suffer from symptoms of vaginal atrophy.7,12 Through proper screening, detection, and management of this condition, clinicians have an opportunity to positively affect quality of life in this growing segment of the population.
Pathophysiology
The female urinary and genital structures arise from a common embryologic origin and are abundant with receptors highly sensitive to changing estrogen levels. During the reproductive years, the vaginal mucosa is thick with rugae and glycogen-rich cells. The strong presence of lactobacilli helps to maintain a pH of 3.5 to 4.5, which creates an environment both hostile to pathogenic bacteria and protective against UTI. During the menopausal transition, estradiol levels drop from 120 ng/L to about 18 ng/L.13 The vaginal canal shrinks in length and diameter, and blood flow to the vagina decreases. As a result, the vaginal mucosa becomes thin and pale, with decreased elasticity and loss of rugae. The tissues become dry and more friable, leading to generalized discomfort and dyspareunia. There are fewer glycogen-rich cells and therefore few or no lactobacilli present. The vaginal pH rises to higher than 5, allowing colonization by more pathogenic bacteria such as streptococci, staphylococci, coliforms, and diphtheroids. 13 The distance from the urethral opening to the vaginal introitus is reduced secondary to decreased collagen content and tissue atrophy.6 This and changes in vaginal flora increase susceptibility to UTI.
Predisposing factors
Urogenital atrophy is a direct result of reduced estrogen levels. The predominant cause is menopause, either 
natural or secondary to oophorectomy. However, multiple factors have been implicated in the development of atrophic vaginitis (see Table 2). Radiation therapy, chemotherapy, and various immune disorders can contribute to decreased estrogen levels. Additionally, women who require antiestrogenic medicines such as medroxyprogesterone, tamoxifen, danazol, leuprolide, or nafarelin may experience atrophic symptoms.7 Women who are in the postpartum period and those who are lactating also experience diminished estrogen levels due to placental loss and the action of elevated prolactin.7 Smokers may experience worsened atrophy secondary to increased metabolism of estrogen, but study results have been somewhat conflicting thus far.12,14 Finally, women who have never given birth vaginally or who tend to have nonfluctuating levels of estrogen are at increased risk of symptomatic atrophic vaginitis.15 Continued sexual activity, including masturbation, has been shown to increase genital blood flow, help maintain the elasticity of urogenital tissues, and delay the onset of atrophic symptoms.7,12
Clinical presentation
Atrophy may first be apparent on external genital examination. The examiner will note decreased elasticity of the external genitalia, dryness of the labia, and possibly the presence of vulvular lesions.6 The labia majora appear shrunken, and the labia minora may be fused or even disappear altogether.7,12 The vaginal introitus is often narrowed and the depth of the vagina itself reduced.7 (A small speculum should be used for the examination, as atrophic tissues are highly susceptible to trauma and the examination can often be painful.) The epithelial walls are generally “pale, smooth, shiny, and dry.”13 The thinning epithelium demonstrates loss of rugae and is often friable, leading to submucosal petechial hemorrhage and, occasionally, bleeding.12 Additionally, a malodorous yellow discharge may be present.7 The presence of rectocele or cystocele should be noted. It is important to be aware that bacterial vaginosis, vaginal candidiasis, trichomoniasis, and tissue irritation from incontinence or the use of hygiene products can cause similar symptoms and may mimic or coexist with atrophic vaginitis (see Table 3). Be sure to evaluate women for these conditions even when you are relatively certain of the diagnosis of atrophic vaginitis.