Find comprehensive information on vaginal atrophy, including clinical documentation, medical coding (ICD-10), symptoms, causes, and treatment options. Learn about genitourinary syndrome of menopause (GSM), atrophic vaginitis, urogenital atrophy, and relevant healthcare terminology for accurate diagnosis and coding. Explore resources for managing vaginal dryness, burning, itching, and painful intercourse associated with vaginal atrophy. This resource supports healthcare professionals in providing optimal patient care.
Also known as
Atrophic vaginitis
Thinning and inflammation of the vaginal walls due to estrogen deficiency.
Female genital inflammation, unspecified
Inflammation of female genitalia without further specification.
Estrogen deficiency
Low estrogen levels, a common cause of vaginal atrophy.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the vaginal atrophy postmenopausal?
Yes
With other symptoms?
No
Is it due to artificial menopause?
When to use each related code
| Description |
|---|
| Vaginal thinning, dryness, inflammation |
| Vulvovaginal candidiasis |
| Bacterial vaginosis |
Coding N28.8 (Female genital organs NOS) instead of N85.5 (Atrophic vaginitis) when clinical details support the latter, leading to under-reporting of specific diagnosis.
Failing to document or code the underlying cause of vaginal atrophy, such as postmenopausal status (e.g., N95.1), impacting data accuracy and reimbursement.
Coding symptoms (e.g., dyspareunia, dryness) without coding the underlying diagnosis of vaginal atrophy (N85.5), obscuring the true clinical picture.
Patient presents with complaints consistent with vaginal atrophy (atrophic vaginitis), including vaginal dryness, itching, burning, and dyspareunia. Symptoms impact quality of life and sexual health. On examination, pale, dry vaginal mucosa with decreased rugae is noted. Minimal clear discharge present. Patient reports decreased vaginal lubrication during intercourse. Symptoms began approximately two years ago, coinciding with menopause onset. Denied vaginal bleeding or abnormal discharge. Differential diagnosis includes vulvovaginal candidiasis, bacterial vaginosis, and contact dermatitis. Based on patient history, physical exam, and absence of other infectious findings, the diagnosis of vaginal atrophy is made. Discussed the pathophysiology of vaginal atrophy related to estrogen deficiency. Treatment options including vaginal moisturizers, lubricants, and local estrogen therapy were reviewed. Patient opted to initiate over-the-counter vaginal moisturizer for daily use and a lubricant as needed for sexual activity. Patient education provided on the benefits and risks of each treatment option. Scheduled follow-up in three months to assess symptom improvement and discuss potential escalation of therapy if needed. ICD-10 code X28.0, atrophic vaginitis, is assigned. Patient advised to return sooner if symptoms worsen or new symptoms develop.