the result of a physiologic decline in estrogen production from depleted ovarian follicles.

Reduced estrogen levels associated with menopause cause decreased blood flow and reduced collagen and glycogen content in vulvovaginal tissues→that result in the loss of epithelial elasticity and subsequent atrophy.  The atrophic urogenital epithelium becomes thin, dry, and easily denuded, making it more susceptible to injury (eg, trauma, infection). Therefore, even minimal tissue manipulation (eg, wiping with toilet paper) can cause vestibular fissures and vaginal petechiae, leading to vulvar or vaginal bleeding.

the associated urinary symptoms of atrophic vaginitis:

• Decreased collagen, elasticity, and blood flow in the bladder trigone and urethra (which are estrogen-sensitive tissues) result in urogenital atrophy, which can induce urgency incontinence (urgency followed by immediate loss of urine), often causing wet undergarments and nocturia (as seen in this patient).
• Decreased glycogen content results in loss of vaginal lactobacilli and an elevated vaginal pH, which increase the risk of recurrent urinary tract infections. At the vulva, decreased glycogen content results in a thin, easily denuded vulvovaginal epithelium that causes dysuria when in contact with urine.

| Symptoms | • Vulvovaginal dryness and palness, irritation, pruritus with petechiae (due to easily denuded epithelium) and patchy erythema • Vulvular skin thining • Dyspareunia due to narrowing of the vagianl intoritus and loss of natural lubrication • Minimal vaginal discharge with Ph >4.5 due to decreased lactic acid production from low glycoprotien content • Vaginal bleeding with minimal manipulation (wiping with toilet paper • Urinary incontinence, recurrent urinary tract infection (mimics UTI) • Pelvic pressure | | --- | --- | | Physical examination | • Sparse pubic hair • Narrowed introitus • Pale easily denuded mucosa, ↓ elasticity, ↓ rugae • Atrophic epithilium resulting in clitoral shrinkage, loss of vagnial rugae and shortened vagina (cervix flush with vaginal wall) • Petechiae, fissures • Loss of labial volume | | Diagnosis | • Clinically; however, an elevated vaginal pH ≥5 may help confirm the hypoestrogenic state because reduced glycogen production reduces normal vaginal lactobacilli activity. | | Treatment | • Vaginal moisturizer & lubricant (first line) if no improvement → • Topical vaginal estrogen ( cream, tablet, ring ) which increases Blood flow and glycogen content |

• EDUCATIONAL OBJECTIVES
• DDx

According to JUH its the MCC of postmenopausal bleeds