http://www.medscape.com/viewarticle/458970_2

Amy R. Palmer, CNM, MSN, Frances E. Likis, CNM, MSN, FNP

Abstract and Case Description
Abstract
Atrophic vaginitis is typically associated with the hypoestrogenic state of
menopause. However, lactation also decreases estrogen levels and can cause
symptomatic urogenital atrophy. Discussion of this clinical phenomenon in
the literature is minimal. A case report of atrophic vaginitis at 13 months
postpartum is presented. Mechanisms of action, evaluation, and treatments
for lactational atrophic vaginitis are reviewed with recommendations for
further research on this topic.

Case Description
A 28-year-old primipara woman presented to the birth center at 13 months
postpartum. She reported discomfort with urination, vaginal itching and
dryness, and severe pain during intercourse described as "someone ripping
out her insides." She had intercourse only four times since giving birth
and experienced significant pain each time. She tried lubricants to relieve
her symptoms, as well as increased foreplay to improve arousal and vaginal
secretions. These measures provided only minimal relief. She has been
breastfeeding her daughter since birth and remains amenorrheic. Her
pregnancy and birth were uncomplicated, and she has an unremarkable medical
history. A discussion about her relationship revealed a strong love for her
husband and concerns that her inability to be intimate with him was ruining
their marriage.

On external genital examination, her vulva was pale pink, shiny, and
inflamed with small areas of erythema and petechiae present. Her vaginal
tone was strong; in fact, the muscles were so tight that she found it
difficult to relax them and was uncomfortable with the speculum
examination. Her cervix and vaginal walls had the same appearance as the
outer genitalia, and there was very little vaginal discharge noted. A
saline and potassium hydroxide (KOH) wet preparation was performed with the
findings of white and red blood cells, very few lactobacilli, and no clue
cells or hyphae. Thus, there was no evidence of infection.

Based on her history and examination, a diagnosis of atrophic vaginitis
related to lactation was made. Because previous self-help measures had been
unsuccessful, she was offered vaginal estrogen cream. She was conflicted
between the desire to resolve her symptoms and concern about the effect of
estrogen on milk production, but she elected to use the cream after
thorough counseling and careful consideration of her options. After 2 weeks
of using 17-estradiol cream two to three times a week, she was feeling
better and the symptoms were subsiding. She called the birth center to
report that the treatment was working, she was still nursing with no
decrease in milk supply, and intercourse was much more enjoyable.



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