Atrophic vaginitis (genitourinary syndrome of menopause)

What it is

Atrophic vaginitis is one of the transient causes of urinary incontinence, the A of the DIAPPERS mnemonic:

• Delirium
• Infection, that is acute urinary tract infection
• Atrophic vaginitis
• Pharmaceuticals
• Psychological disorder, especially depression
• Excessive urine output, for example hyperglycemia
• Reduced mobility, that is functional incontinence, or reversible urinary retention, for example drug-induced
• Stool impaction

Because the cause is transient, the incontinence is reversible, and that is what sets this group apart from the chronic types. Atrophic vaginitis itself belongs to the postmenopausal woman. It presents with post-coital bleeding in postmenopausal women, dyspareunia, vaginal dryness and itchiness, and that group of symptoms is what puts the name on it. Menopause is marked on investigation by low estrogen (E2), low progesterone and low total androgens, with high FSH, high LH and high estrone (E1) from peripheral conversion. Estrogen loss works on tissue that depends on it. The cells lining the vagina and urethra are estrogen-dependent: normally the vagina has a thick moist epithelium with acidic secretion at a pH of 4.0, and the absence of estrogen gives a thin, dry epithelium with alkaline secretion at a pH above 7.0. Put another way, it is thinning and ulceration of the vaginal mucosa from hypoestrogenism, usually in a postmenopausal woman not on any hormone replacement therapy, and estrogen is what acts on the glands that produce fluid and mucus to keep the vagina moist, makes the lining thicker and more elastic, and stimulates the cells to produce glycogen. Low oestrogen from causes other than menopause, from drugs or from RXT or CXT, does the same.