Genitourinary syndrome of menopause presents with dryness, dysuria, urgency and dyspareunia on a background of vulvovaginal pallor, epithelial thinning, loss of rugae and mucosal atrophy. So do several vulvar dermatoses, and the overlap is the problem this review addresses: symptoms alone cannot separate them, and a woman labelled with the syndrome and given topical oestrogen may have lichen sclerosus scarring quietly underneath.
The framework offered is morphology-driven rather than symptom-driven. Look at the lesion — its morphology, its distribution, and any associated findings elsewhere on skin and mucous membranes — because that is what distinguishes inflammatory, infectious and neoplastic vulvar disease from a hypo-oestrogenic state. The review is explicit that a structured examination plus timely biopsy where indicated is what improves accuracy.
It also names the referral triggers, which is the useful operational part: diagnostic uncertainty, refractory or multisite disease, scarring or functional impairment, or a need to escalate to systemic or advanced therapy. Those are worth writing into a clinic protocol, because the failure mode here is not a wrong diagnosis made once — it is a woman treated for atrophy for two years while architecture is lost. This is a narrative review offering expert structure rather than comparative evidence, and it should be read as such.
- Examine and describe lesion morphology and distribution before attributing symptoms to atrophy
- Look beyond the vulva — associated mucocutaneous findings often make the diagnosis
- Biopsy where the appearance is not typical, rather than trialling oestrogen and reviewing in six months
- Refer for uncertainty, refractory or multisite disease, scarring, functional impairment, or need for systemic therapy
- Any loss of architecture or scarring is a reason to stop assuming genitourinary syndrome of menopause
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