Determining the cause and appropriate treatment of vulvovaginitis in the postmenopausal woman is complicated by the effects of decreased endogenous estrogen as well as normal aging changes. The symptoms of vulvovaginitis remain the same at any age but after menopause these symptoms can be the result of atrophy alone. Estrogen is the treatment of choice for atrophic vaginitis. The differential diagnosis and treatment of sexually transmitted diseases, candidiasis, and vulvar dystrophies are described and various alternatives to estrogen use are included.