Postpartum Vaginal Dryness and Atrophic Vulvovaginitis
by Dr Sarah Little, General Practitioner MBChB BSc Hons MRCGP DCH DRCOG DFSRH
Oestrogen levels drop at delivery and remain low for the first several months of breastfeeding or longer1. Prolactin exerts an antagonistic effect on oestrogen production. In some women this may result in vaginal dryness, vulval pain, dyspareunia and atrophic vulvovaginitis. Hypoestrogenaemia may also cause urinary symptoms such as dysuria, urgency, and frequency2. Discussion of this clinical phenomenon in the literature is minimal. The prevalence of postpartum vaginal dryness ranges from 17% by vaginal examination3 to 46% by patient report4.
Examination is important in the diagnosis of vulvovaginal atrophy. Shrinking and dryness of the labia may be noted, as well as inflammation and erythema of the vulva. The walls of the vagina may appear pale with poor rugation, and patches of inflammation may be present. Petechiae and ecchymosis may also be noted, and vaginal and cervical secretions are typically decreased. Friability can occur due to the fragility of the vaginal mucosa. Speculum insertion for examination may be difficult and painful due to stenosis of the introitus and vaginal dryness. Decreased oestrogen levels cause the vaginal pH to become more alkaline, typically with levels greater than 5.0. pH can be tested at the beside with litmus paper1,5.
For patients requesting treatment, topical oestrogen twice weekly may be considered and can result in dramatic improvement5,6. Emollients are also useful as a soap substitute and as a moisturiser.
When oestrogen is prescribed to a breastfeeding woman, it is important that she is counselled about the potential effects of oestrogen replacement on return of fertility and compromised milk supply7. In reality, topical oestrogen is unlikely to have a significant effect on milk production once breastfeeding is established (see also our page on ‘Family Planning‘ for information on UK MEC recommendations regarding oral combined hormonal contraceptives).
Correspondence with the UK Drugs in Lactation Advisory Service in March 2017 advises topical oestrogens should be avoided in mothers breastfeeding infants under 6 weeks of age due to the possibility that milk supply may be affected by the systemic absorption of oestrogen. Beyond 6 weeks they may be used at the prescriber’s discretion but mothers should be counselled regarding possible effect on milk supply.
Because women may not self-report such symptoms, it is important to ask about postpartum vaginal and sexual health. Lactational atrophic vulvovaginitis can be a distressing problem to breastfeeding mothers and is probably under-recognised5.
For general information on atrophic vulvovaginitis see:
DermNet New Zealand: Atrophic Vulvovaginitis Information for clinicians.
Vulval Pain Society: Pregnancy and Vulval Pain Useful resource for patients experiencing conditions causing vulval pain.
- The Breastfeeding Answer Book Mohrbacher N. & Stock J., La Leche League International (3rd ed. (revised ed.) 2003)
- Bachmann G, Nevadunsky N. Diagnosis and treatment of atrophic vaginitis. Am Fam Physician 2000;61(10):3090-6.
- Wisniewski P, Wilkinson E. Postpartum vaginal atrophy. American Journal of Obstetrics and Gynecology. 1991;165(4):1249-1254.
- Barrett, G., Pendry, E., Peacock, J., Victor, C., Thakar, R. and Manyonda, I. Women’s sexual health after childbirth. BJOG: An International Journal of Obstetrics & Gynaecology, 2000;107:186–195.
- Palmer A, Likis F. Lactational atrophic vaginitis. Journal of Midwifery & Women’s Health. 2003;48(4):282-284.
- Adam P, Madlon-Kay D. What is the prevalence of vaginal dryness postpartum and what is the best treatment? Evidence Based Practice. 2012;15(12):08-09
- Breastfeeding and Human Lactation Riordan J. & Auerbach K., Jones and Bartlett (2nd ed. 1998)