The Genital Tract
Change in menstrual bleeding are amongst the key symptoms and signs that herald the effects of the onset of the menopause on the endometrium. They occur relatively soon during the process of menopausal transition. However it is important to consider that other areas within the genital tract such as the vulva, vagina and urinary tract may also be affected.
The initial irregular or scanty vaginal bleeding is due to the reduction in estrogenic endometrial stimulation with failing ovarian function, ultimately resulting in periods completely stopping when the endometrium is no longer stimulated.
Episodic and infrequent ovulation with fluctuations in estrogen levels leads to unpredictable progestogenic levels which usually has the effect of inadequate regular endometrial shedding. This can then lead to some women experiencing irregular heavy bleeding.
The Urogenital Tract and Vulvo-Vaginal Atrophy
Once estrogen levels start to fall in the perimenopausal years many women, particularly those who are sexually active, may become aware of vaginal dryness, irritation, burning, soreness and dyspareunia. Loss of the estrogenic support to the vaginal epithelium leads to reduced cellular turnover and reduced glandular activity, leading to a vaginal epithelium that is less elastic and more easily traumatised. Other conditions that frequently worsen during the menopause including incontinence and prolapse are covered later.
The inherent resistance of the urogenital system to infection is also impaired, considered to be due to an increase in pH of the normal mildly acidic environment within the vagina. The incidence of urinary tract infections is also increased, as is the incidence of episodes of minor episodes of cystitis that accompany sexual activity.
Examination of women with postmenopausal urogenital atrophy normally demonstrates dryness affecting most of the surfaces along with pallor and in extreme cases small petechial haemorrhages. Older women may also have shrinkage and fusion of the labiae along with narrowing of the vaginal introitus.
All women experience these changes in the lower genital tract to some degree. It is an intimate area that many women may have difficulty raising in conversation even though they may be experiencing severe symptoms soit is therefore very important that healthcare professionals looking after these women proactively ask about and manage these issues.