Have you noticed that things are a little different down there? While it’s common to hear about hot flashes and sleepless nights, people tend to keep quiet about the more personal changes that happen with menopause, such as vaginal tightness, dryness, pain, and uncomfortable sex. Read on for all the info you won’t get from a group chat.
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Hormones and your vagina
At the time of menopause, your ovaries stop producing estrogen. While this affects many different parts of the body, the dramatic reduction in hormone levels can be particularly troublesome when it comes to the tissues in and around your vagina. This is because these tissues are rich in estrogen receptors.
During premenopause, the presence of estrogen keeps these tissues plump, resilient, and healthy. Once estrogen is removed, you begin to notice changes that can be annoying and in some cases quite distressing. Tissues become thin, sore, and inflamed – this condition is called vaginitis.
These changes can also be referred to as:
- Vaginal atrophy
- Atrophic vaginitis
- Vulvovaginal atrophy
- Genitourinary syndrome of menopause (GSM)
In this article, we will use the most recent term, GSM, although these terms are often used more or less interchangeably.
What genital symptoms should you look out for?
Tissues sensitive to estrogen are found in your vagina, around the external genitals, and in the urethra and bladder. As you would expect, this means that there is a wide range of symptoms caused by hormone changes around menopause.
Genital symptoms can affect the vagina and the external genitalia, including:
- Dryness, which happens due to decreased secretions
- Discharge (usually white or watery)
- Painful sex
- Bleeding, including bleeding after sex
- Recurrent urinary or vaginal infections
- Pain on sitting down or wiping
You may also notice urinary symptoms, including recurrent urinary tract infections, pain when peeing, blood in your pee, and needing to pee more often.
Find out more about urinary symptoms.
Let’s take a closer look at some of the most common vaginal symptoms…
Burning, itching and pain
You may experience burning, itching, and pain either internally or externally. This can be extremely uncomfortable and disruptive and is one of the most common symptoms of GSM. In some cases, it can even be severe enough to disrupt normal activities, including cycling and sitting down.
This happens when typical menopausal changes to the genitals are accompanied by inflammation. The same process can also cause bleeding and changes in appearance.
Several of the changes seen in menopause can contribute to painful sex. As the effect of estrogen wanes, the vaginal walls become thinner and more delicate, with a loss of the folds and elasticity which would previously have allowed the vagina to stretch during sex. Add to this reduced natural lubrication and a tendency for the vagina to become narrower and shorter, and you have a recipe for painful sex.
You may also find sex less pleasurable. This happens because blood flow to the area is reduced and because the nerves supplying the genital area also work more effectively in the presence of estrogen (which is now in decline).
There are several things you can do to make things more comfortable. Use a water-based lubricant and try to have sex regularly (as this can help maintain the vaginal tissues). Pelvic floor exercises can also help, as they stimulate blood flow to the area and encourage lubrication as well as keeping the pelvic floor muscles in shape.
Changes in appearance
You may also notice that you look different down there after going through menopause. This is normal and just like the other symptoms of GSM is due to reduced estrogen levels – blood flow to the area decreases, and collagen and elastin levels drop.
Tissues including the vulva, labia, and clitoral hood can all be affected. You may notice that you have less pubic hair and that your labia seem to shrink or even disappear. Some may find that the labia fuse and that the vaginal opening narrows. Internally, the vaginal walls often become paler, drier, and smooth in texture.
Vaginal and uterine prolapse also becomes more common around this time. Speak to your healthcare provider if you notice any fleshy lumps in or protruding from the vaginal opening, especially if they are associated with discomfort, changes to your bowels or bladder, or a dragging sensation.
Read more about prolapse.
When do changes to your vagina happen?
It varies. Some will begin to notice changes to their vagina and genitals happening alongside the first symptoms of menopause. Others may only begin to notice problems several years after their other menopause symptoms have disappeared.
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When should you see a healthcare provider?
If you have any symptoms that are bothering you, including any from the list above, book an appointment! While this is not an easy subject to talk about, your healthcare provider will have dealt with this problem many times over and can offer effective treatments.
It is important to note that some symptoms of GSM can be caused by other conditions, therefore it’s important to get them assessed properly by your healthcare provider. Book in as soon as possible if you have any vaginal bleeding, blood in your pee, sores or ulcers on the genitals, severe pain, or anything that is particularly worrying you.
Read our guide to red-flag symptoms where you need to talk to a healthcare provider.
Are there treatments that work?
The most effective treatment is hormone therapy (HT). This involves taking estrogen supplements, which allow the tissues to heal thanks to those estrogen receptors mentioned earlier. It usually takes a few months to see their full effect, but most will eventually notice a significant improvement in their symptoms, including changes in appearance.
Unlike most menopausal symptoms, GSM can be treated effectively with topical HT. This means that the estrogen is applied directly to the vaginal and/or genital tissues in the form of a cream, ring, or suppository (internal tablet).
Read more about HT risks and benefits.
While other forms of HT come with warnings about side effects, the risk with topical HT is extremely low. This is because the type of estrogen used is both much less potent than that used in other forms of HT, and is not absorbed into the bloodstream. Topical HT is therefore safe for most people, although you should always check with your healthcare provider before starting treatment, especially if you have a history of breast cancer.
The amount of HT that you need will also vary. It is normal to begin by applying the product each day for two weeks followed by a gradual reduction in frequency. Once recovered, many will be able to wean this down to a couple of times per week or even less.
Systemic HT (usually in the form of a tablet or patch) may also help with your symptoms of GSM, although it is not usually given for GSM alone. Some on systemic HT may also need topical HT to fully treat genital symptoms. Speak to your healthcare provider to find out which option is best for you.
It is also important to pay attention to hygiene and skincare, yes, even down there, as the skin becomes more delicate and prone to inflammation and infection after menopause. Try using a soap substitute to cleanse. Options include Dove sensitive skin bar, Vagisil body wash, and others, which can be bought at your local pharmacy.
Wear cotton underwear and looser clothes, and avoid using sanitary towels and pantyliners where possible. Speak to your healthcare provider if you are having trouble with leaking pee, as this can also contribute to inflammation in the vulvar area.
Washing your vagina or using a douche should generally be avoided. It usually does more harm than good.
Vaginal moisturizers may also help, especially if you are struggling with dryness. These can be purchased at a local pharmacy and common brand names include Replens and Vagisil. Be sure to follow the product instructions carefully and if you are planning to use an internal moisturizer ensure that the product you buy is appropriate for this. Be aware that there is a difference between vagina moisturizers (which help to treat dryness at any time) and lubricants (which are specifically used to make sex more comfortable).
If you do not find much improvement, it may also be worth considering seeing a physiotherapist for an assessment of your pelvic floor. Your healthcare provider will be able to advise whether this is necessary.
However these changes affect you, remember that effective and safe treatments are available. You don’t have to put up with it if you don’t want to! Your healthcare provider will be able to discuss the best treatment options for you.