A 53-year-old woman with a history of HIV infection and hypothyroidism presents with complaints of vaginal itching, burning, and dyspareunia. She has been avoiding sexual intercourse with her husband due to these symptoms. She denies any vaginal discharge, bleeding, dysuria, or hematuria. She has occasional hot flashes, which have not been bothersome.

Medications include dolutegravir, tenofovir alafenamide/emtricitabine, and levothyroxine. The patient’s last CD4 cell count was 524 cells/µL, and her HIV-1 RNA was undetectable. Her last menstrual period was 2 years ago. She had a normal Pap smear recently. Her pelvic examination is notable for pale vaginal mucosa with decreased rugae and petechial hemorrhages. Bimanual examination is unremarkable. Urinalysis is unremarkable, and whiff test is negative. Microscopy is negative for clue cells, hyphae, or yeast.