A 55-year-old woman comes to the office due to occasional bloody spotting on her toilet paper over the past few weeks. The patient has no hematuria, dysuria, hematochezia, melena, heavy vaginal bleeding, or vulvar pruritus. Her last menstrual period was 4 years ago. She had a normal Pap test last year with no history of abnormal results. She has no medical conditions and takes daily supplements of calcium with vitamin D. The patient is not sexually active and does not use tobacco, alcohol, or illicit drugs. BMI is 32 kg/m². Pelvic examination shows sparse pubic hair and fissures along the vestibule. The vagina has multiple areas of petechiae; the cervix is flush with the vaginal wall. There is minimal clear vaginal discharge but no active bleeding. Vaginal pH is 6. Urinalysis is normal. Fecal occult blood test is negative. Pelvic ultrasound reveals a small, anteverted uterus with a 3-mm endometrial stripe. Which of the following is the most likely explanation for the findings in this patient?

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11ec25c8_d9f1_76db_bc81_6d6f67f56cc5_MD0003_00 This patient has genitourinary syndrome of menopause (or atrophic vaginitis), the result of a physiologic decline in estrogen production from depleted ovarian follicles. Low estrogen levels cause diminished blood flow and decreased collagen and glycogen production in the 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. Physical examination shows sparse pubic hair, loss of vaginal rugae, pallor, and a shortened vagina (eg, cervix flush with vaginal wall). The diagnosis is made clinically; however, an elevated vaginal pH ≥5 may help confirm the hypoestrogenic state because reduced glycogen production reduces normal vaginal lactobacilli activity. Treatment includes vaginal moisturizers and vaginal estrogen. (Choice B) Malignant proliferation of the endometrium (eg, endometrial cancer) is a cause of postmenopausal bleeding. Although this patient's obesity (BMI ≥30 kg/m²) increases her endometrial cancer risk, this diagnosis is unlikely given the thin endometrium (≤4 mm) on ultrasound. ² (Choice C) Overgrowth of anaerobic vaginal flora (eg, Gardnerella vaginalis) leads to bacterial vaginosis and an elevated vaginal pH (eg, >4.5). However, bacterial vaginosis has a gray, malodorous vaginal discharge (not seen in this patient) with no associated vaginal bleeding, fissures, or petechiae. (Choice D) Vaginal intraepithelial neoplasia is typically associated with human papillomavirus infection and concurrent cervical dysplasia. When symptomatic, it presents with abnormal vaginal bleeding and discharge; however, this patient has normal Pap tests, making this diagnosis unlikely. (Choice E) Vulvar epithelial plaque formation describes lichen sclerosus, which typically presents with vulvar pain, pruritus, and wrinkled white plaques on examination (not seen in this patient). lichen sclerosus Educational objective: The genitourinary syndrome of menopause, or atrophic vaginitis, causes vulvar and vaginal atrophy from loss of epithelial elasticity due to low estrogen levels. The hypoestrogenic state renders the urogenital tissues thin, dry, and inelastic, making them more susceptible to injury (eg, petechiae, vestibular fissures) and bleeding. References: Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition? (http://www.ncbi.nlm.nih.gov/pubmed/26707589) ACOG practice bulletin no. 141: management of menopausal symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/24463691) Hormone therapy and other treatments for symptoms of menopause. (http://www.ncbi.nlm.nih.gov/pubmed/27929271)

A 55-Year-Old Woman Comes to the Office Due to Occasional