The Vagina :Bringing the Vagina Back to Life After Menopause Non-Hormonal Treatment Approaches for Atrophic Vaginitis and Chronic UTIs in Estrogen-Restricted Women In honor of the women who have suffered in silence

Submitted by Stefanie A. Varela, Ph.D., WHNP-BC, FNP-C and Delfino Varela, Medical Student

The Vagina :Bringing the Vagina Back to Life After Menopause Non-Hormonal Treatment Approaches for Atrophic Vaginitis and Chronic UTIs in Estrogen-Restricted Women In honor of the women who have suffered in silence

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Introduction

This paper is dedicated to the many women I have had the privilege of treating for atrophic vaginitis during menopause. Atrophic vaginitis—characterized by vaginal dryness, tissue thinning, and the involution of the vagina, labia, and urethra—is primarily caused by estrogen deficiency. I reflect on the voices of women whose needs have been unmet due to contraindications for estrogen therapy, often stemming from a history of cancer or other medical concerns. This work seeks to explore evidence-based, non-hormonal alternatives to manage atrophic vaginitis in menopausal women who cannot undergo estrogen therapy.

Atrophic vaginitis does not affect the vagina alone—it also compromises the urethra, labia minora, labia majora, and the vaginal introitus (Faubion et al., 2017). Many of my patients have expressed frustration and distress as they navigate these symptoms without access to estrogen treatment. Their suffering and pleas for relief fuel the urgency of exploring and validating safe, effective, and estrogen-free therapeutic options.

When You Hear “Chronic Vaginitis,” Think Beyond the Diagnosis

The term chronic vaginitis should prompt providers to perform comprehensive assessments of the entire vulvovaginal complex: the vagina, urethra, labia minora, and labia majora. Are these tissues thinning, dry, or atrophic? Do they require localized intervention?

In many older adults, particularly the geriatric population, antibiotics are prescribed reflexively. However, these patients often lack the gut microbiome resilience to tolerate repeated antimicrobial exposure, resulting in dysbiosis and worsening long-term health (Kingsberg et al., 2013; NAMS, 2022).

Understanding Atrophic Vaginitis

Atrophic vaginitis—now more broadly referred to as Genitourinary Syndrome of Menopause (GSM)—involves thinning, drying, inflammation, and reduced elasticity of urogenital tissues. It impacts not only comfort but also sexual health, urinary function, and quality of life (Faubion et al., 2017).

A significant concern in estrogen-deficient patients is receptor site desensitization, affecting orgasmic function and sensory stimulation at the clitoris and Skene’s glands (Kingsberg et al., 2020). In these cases, non-hormonal tools like lubricants and vibratory devices can stimulate blood flow and reawaken neural pathways (Goldstein & Traish, 2015; Perelman et al., 2018).

Chronic UTIs: Reassessing Etiology in Menopausal Women

Too often, recurrent UTIs are treated without identifying urethral atrophy as the true culprit. Research shows:

  • Over 47% of postmenopausal women are not examined vaginally during routine care (Kingsberg et al., 2013).
  • Up to 60% of postmenopausal women report UTI symptoms, often due to urogenital atrophy, not infection (NAMS, 2022).

Providers should move beyond reflex antibiotic prescribing. Topical compounded estriol (E3)—when appropriate—can be gently massaged into the vaginal wall, labia, and perineum to restore tissue health. If E3 is contraindicated, alternative approaches must be explored.

Alternative Treatments

1.    Coconut Oil

  • Use: Apply 100% organic coconut oil twice daily to vaginal and vulvar tissues.
  • Benefit: Moisturizing and antimicrobial (DebMandal & Mandal, 2011; Verallo-Rowell et al., 2008).

2.    Castor Oil

  • Use: Apply externally at night, alternating with coconut oil.
  • Benefit: Anti-inflammatory and emollient (Dibazar et al., 2022; Kim et al., 2015).

3.    Vitamin E Oil

  • Use: Apply every other night to internal and external vaginal tissues.
  • Benefit: Antioxidant, reduces inflammation (Gerhard & Reilly, 2015; Kumar et al., 2017).

4.    Hyaluronic Acid Suppositories

  • Use: Prescribed daily, then taper based on cost and efficacy.
  • Benefit: Improves hydration and elasticity (Fina, 2018; Piskin et al., 2020).

5.    Platelet-Rich Plasma (PRP)

  • Use: Injected into vaginal tissue for regenerative support.
  • Benefit: May improve mucosal thickness and sensation (Jang et al., 2019; Gunter et al., 2021).

6.    External Devices (e.g., Lelo Sona, Gigi, vibrators)

  • Use: Encourage gentle, regular use to promote circulation.
  • Benefit: Stimulates nerve endings and blood flow, aids in tissue revitalization (Perelman et al., 2018; Simpson et al., 2021).

Conclusion

For women unable to use estrogen, atrophic vaginitis remains a debilitating, under-treated condition. While alternatives may not fully regenerate vaginal tissue, they offer meaningful symptom relief. This paper aims to elevate awareness and clinical responsiveness to this issue, honoring the experiences of women whose suffering has too long been silenced. As emerging science suggests, localized therapies—whether hormonal or mechanical—can restore integrity, sensation, and dignity.

References 

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