Genitourinary syndrome of menopause (vulvovaginal atrophy, vaginal atrophy, atrophic vaginitis, urogenital atrophy) is associated with low estrogen levels. Therefore, it typically affects menopausal / postmenopausal women but can also occur in premenopausal women who have low systemic estrogen levels caused by a postpartum state, lactation, or antiestrogenic drugs. Prevalence is below 3% in premenopausal women and rises to 47% after 3 years postmenopause. Symptoms are rarely dangerous but impact quality of life in many affected patients.

Estrogen acts on the urogenital tract, including the vaginal epithelium, vulvar tissues, urethra, and bladder. In the vaginal epithelium, estrogens induce collagen content, acid mucopolysaccharides, and hyaluronic acid, which all maintain tissue thickness, elasticity, vaginal rugae, and glycogen stores, which are a substrate for lactobacilli. Lactobacilli in turn maintain the acidic vaginal pH that promotes normal flora in the genital tract and serves as a barrier to vaginal and urinary tract infections.

Serum estradiol in postmenopausal women is on average 5 pg/mL, compared with 40-600 pg/mL in premenopausal women. This drop induces many changes in urogenital tissue. The vaginal epithelium becomes thin and loses elasticity. The vaginal canal shortens and loses rugae. Loss of glycogen stores and lactobacilli colonization allow the vaginal environment to become less acidic, with pH >5.0. Thin vaginal epithelium is more prone to damage from minor trauma, causing underlying connective tissue to become exposed and making it susceptible to inflammation and infection.

Women often first present reporting decreased vaginal lubrication during intercourse. Other common symptoms include dyspareunia, vaginal dryness, burning, or irritation. Tissue irritation can also lead to vulvar or vaginal bleeding.

Bladder and urethral epithelium can atrophy as well without the influence of estrogen, which can lead to urinary tract infections, dysuria, increased urinary frequency, and rarely hematuria.

Menopause is the leading cause of low estrogen levels and the leading risk factor for vaginal atrophy. Other causes of low estrogen levels include bilateral oophorectomy, premature ovarian failure, antiestrogenic medications, and postpartum or lactation-induced hypoestrogenism. Cigarette smoking is another risk factor because it causes relative estrogen deficiency and impairs tissue perfusion. Regular sexual activity can improve symptoms of atrophy as it promotes tissue perfusion and elasticity. Symptoms generally worsen with time, even if estrogen levels remain stable.