Menopause and Your Vagina

A sign saying 'menopause ahead'

My family are often amused by the books I read. They found the title of one of the recent ones especially funny – “Me & My Menopausal Vagina”. However, while told in a light-hearted way, the subject matter is nothing to be laughed at.

British author, Jane Lewis, recounts her experience with menopause, and in particular with vaginal atrophy. This left her in severe daily pain, forcing her to give up work and many social activities. Her bladder function and ability to have intercourse were also affected. While not every woman going through menopause experiences vaginal atrophy, and the symptoms are not always so severe, vaginal atrophy is a common problem for many women. It is therefore good to know what vaginal atrophy is and what you can do to prevent and treat it.

What is vaginal atrophy?

Vaginal atrophy refers to the changes that occur in the vagina, but also the vulva, urethra and bladder, as a result of significantly reduced oestrogen levels after menopause. You may also hear it called ‘atrophic vaginitis’. It is now more accurately called ‘genito-urinary symptoms of menopause’ (GSM).

About half of all women experience vaginal atrophy, or GSM, to some extent after menopause. This can occur after natural menopause, but also after induced menopause. The average age of natural menopause in Australia is 51, but it can typically occur between 45 and 55 years old. However, women who have had surgery which has included removal of their ovaries, women who have had chemotherapy or radiotherapy to the pelvic area for cancer, and women who are on medication to suppress oestrogen following breast cancer treatment can all experience an earlier induced menopause as a result of their treatment. Even breast-feeding women can experience a temporary vaginal atrophy, as oestrogen levels are lower while breast-feeding.

Why is oestrogen so important anyway?

Oestrogen is a hormone produced mainly by the ovaries. It is an important hormone in our menstrual cycle and helps give women their typically female body characteristics, such as breasts and wider hips. Our genitals and urinary tissues rely on oestrogen to keep them healthy and elastic, provide a good blood flow to the area, and maintain a slightly acidic pH which helps prevent infections.

During and after menopause, the ovaries stop making oestrogen. While some women may still have some oestrogen in their bodies produced from fat tissue, after menopause oestrogen levels are a lot lower. This combined with the effects of ageing, can cause significant changes all over the body, including in the genito-urinary system. Blood flow is reduced and the skin and tissue lining the urethra and vagina becomes thinner and less plump and elastic. Natural vaginal secretions often dry up too. The pH of the vagina also becomes more alkaline, making infection more likely.

What kind of symptoms can occur with vaginal atrophy?

The most common symptoms of vaginal atrophy are itching and dryness in the genital region. This can become so bothersome that some women will complain of burning pain or discomfort as their clothing rubs on the affected area. For women who are still sexually active, the dryness and itching can make intercourse pretty uncomfortable, or even cause bleeding, and that can trigger more irritation to the tissues. It is not surprising then that many women with vaginal atrophy report a loss of libido as a consequence. Some women’s vaginal tissues can be so wasted from atrophy that the vagina itself can become shorter and tighter, which can literally prevent penetration.

While many women will complain of dryness with vaginal atrophy, some will report a smelly discharge from the vagina. Many women will mistake this for thrush and use over-the-counter treatments which can make things worse, not better. Infections of the vagina and urinary tract are more common after menopause because of the changes in vaginal pH, so unusual discharge should always be properly investigated.

Finally, many women with vaginal atrophy will also complain of annoying bladder symptoms. These can include a greater urgency and frequency of urination, burning with urination and urinary incontinence. While some of these symptoms are also more common with ageing, the thinning of the urethra and irritation from infections with vaginal atrophy are also thought to contribute. Let’s not forget the pelvic floor muscles as well. They can also be adversely affected by reduced oestrogen and become weaker. No wonder urinary symptoms are so common in women of this age group.

Poor Jane Lewis had all of these symptoms in spades!

What can you do about vaginal atrophy?

The good news is help is available – it is such a pity that so many women put up with these symptoms for years and accept them as a normal part of getting older.

  • See your GP – an understanding GP, who you feel comfortable talking to, can be a great resource. They can recommend treatment options and refer you for further investigation if needed. Any unusual discharge, urinary symptoms, bleeding or rash (from itching etc) should always be checked out by your GP first.
  • Start topical oestrogen. Unlike hormone replacement therapy (HRT), topical oestrogen only affects the local genital tissues and has very little, if any, effect throughout the rest of the body. This means some women may still be able to use topical oestrogen after breast cancer - although this should always be cleared with your oncologist first. Topical oestrogen is applied as a cream or tablet (pessary) inserted into the vagina. It helps to improve blood supply to the genital area and makes the tissues more plump and well-lubricated once again. This can definitely help with itchiness and dryness. Many women find it also helps improve their bladder control and reduce bladder urgency.

If you cannot use topical oestrogen, or even if you can but your symptoms are still not completely resolved, there are still other things you can do.

  • Treat your genital area with TLC. Wash only with water (or a very mild product like sorbolene or QV wash) and pat dry gently.
  • Only wear cotton underwear. When you can, try to go without underwear for periods of time (for example in bed at night).
  • Avoid tight clothing and try to remove any damp clothing (including bathers) as soon as possible.
  • Avoid perfumes, colours or other strong chemicals in any product which comes into contact with your genital region. This includes soaps, scented toilet paper, pads and washing powder. Sensitive skin alternatives are available.
  • Find a good vaginal moisturiser. This can be used in addition to topical oestrogen. Olive & Bee intimate cream is an excellent option that is locally made and only contains olive oil and bees wax. Other good options are vitamin E cream or Dermeeze.
  • Use a good quality, low irritant lubricant with intercourse. Again Olive & Bee intimate cream is a great option. YES lubricant is another good option.
  • Do pelvic floor muscle exercises. There is some evidence pelvic floor muscle training may actually improve vaginal atrophy symptoms. Plus is you have any associated urinary symptoms, such as leakage or urgency, they are helpful for those too. See a Women’s Health Physio for advice and help with pelvic floor muscle training.

The main take home message is vaginal atrophy is common in women after menopause but can be effectively treated. It is best to seek treatment sooner rather than later.

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