Development

The female hypothalamic-pituitary-gonadal axis is developed at the time of birth. During the first 5 days of life, the level of gonadotrophin-releasing hormone (GnRH) rises, with a consequent transient rise in gonadal estrogen, attributable to the withdrawal of placental estrogen (98). The estrogen causes prominence of the labia and clitoris and thickening and redundancy of the hymen. The neonatal vagina is purported to measure 4 cm in length (97). Although after 3 months the GnRH levels gradually fall, the estrogenized appearance of the genitalia may persist for the first 2-4 years of life (99,100). During this period, the external genitalia gradually become less prominent; eventually, the hymen becomes thin and translucent and the tissues appear atrophic; occasionally, the hymen remains thick and fimbriated throughout childhood. The nonestrogenized vagina has relatively few rugae and lengthens by only 0.5-1.0 cm in early childhood (97,98).

The hypothalamic-pituitary-gonadal axis is reactivated in late childhood, and the breasts and external genitalia alter accordingly. These changes are classically described in terms of their Tanner stage (101). Under the influence of estrogens, the vagina lengthens to 7.0-8.5 cm in late childhood, eventually reaching its adult length of 10-12 cm (97,98).

The estrogenized vagina is moist because of physiological secretions. This endogenous lubrication is enhanced with ovulation and with sexual stimulation (102). When the endogenous estrogen levels fall resulting from menopause, the vulva and vagina atrophy.

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