Genitourinary syndrome of menopause
Genitourinary syndrome of menopause is the group of symptoms of the genital and urinary tract caused by low oestrogen.
Remember
Low oestrogen thins the lining of the vagina, urethra and bladder and dries the vaginal lining, so vaginal dryness, painful sex and recurrent urinary tract infections form one cluster.
Memory aid
low oestrogen means thin, dry and flat
Use it to recall the typical post-menopausal vaginal change: a thin, dry lining without its folds.
After the menopause (defined as 12 months without a period), the ovaries make very little oestrogen. Oestrogen keeps the vaginal lining thick, moist and elastic. When it falls, the lining becomes thinner, drier, more friable (easily damaged) and less elastic, and the rugae (the folds of the vaginal wall) are lost. Dryness, burning or itching and painful intercourse follow, and these symptoms tend to continue after the menopause rather than settling like hot flushes.
The lower genital and urinary tract share an oestrogen-dependent lining, so the urethra and bladder lining thin as well. In the vagina, loss of surface cells makes the pH more alkaline (less acidic) and lowers the number of lactobacilli (the normally protective bacteria), so harmful bacteria overgrow. That raises the risk of recurrent urinary tract infections, as well as urgency and burning on passing urine.
The urethral lining also becomes thin and irritated, a change called atrophic urethritis, and the urethra's resistance, length and closing pressure fall. A weaker urethral seal makes stress urinary incontinence more likely: urine leaks when pressure inside the abdomen rises, for example on coughing, sneezing or laughing.
Because the problem is local, low-dose vaginal oestrogen can treat it, and vaginal moisturisers and lubricants can be bought at a pharmacy.
Key facts
- Cause
- after the menopause the ovaries make very little oestrogen, and the tissues that depend on it become thin and fragile.
- Vaginal findings
- a thinner, drier, less elastic lining with loss of rugae, causing dryness and painful sex.
- Urinary features
- urgency, burning on passing urine, recurrent urinary tract infections and incontinence.
- Infection risk
- loss of surface vaginal cells raises vaginal pH and lowers lactobacilli, so harmful bacteria overgrow and infection becomes more likely.
- Treatment
- low-dose vaginal oestrogen can reduce recurrent urinary tract infections and improve stress and urgency incontinence.
- Red flag
- any vaginal bleeding after menopause needs a GP check rather than being assumed to be atrophy.
- Not the only cause of stress incontinence
- vaginal childbirth is a leading cause of stress incontinence, so oestrogen loss is one contributor among several.
Exam traps
- Vaginal dryness after the menopause does not come from a rise in progesterone, because progesterone production falls once ovulation stops, and it is the lack of oestrogen that dries the lining.
- Raised FSH (follicle-stimulating hormone) is a true finding after the menopause, but it is a marker of ovarian failure and not the cause of the urinary symptoms, which come from the loss of oestrogen acting on the lining of the urethra and bladder.
- An age-related decline in immune function does not explain vaginal dryness or painful intercourse, whereas thinning of the vaginal, urethral and bladder lining from oestrogen deficiency explains the whole group, infections included.
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