Menopause and Vulvovaginal Atrophy

Some of the most common issues we encounter in Women’s Health are the changes in your body, and in particular your vagina, that happen during menopause.

Written by Elizabeth Oler, MD


Some of the most common issues we encounter in Women’s Health are the changes in your body, and in particular your vagina, that happen during menopause. Although menopause is a fact of life for (technically greater than) half the world’s population, so few people talk about their experiences – even with their close friends and immediate family – that the menopausal transition is still a complete mystery to most women. If she is available, be sure to ask your own mother about her experiences, particularly if she went through natural menopause (rather than surgery-related menopause from premature removal of her ovaries). Daughters and mothers have many similarities. However, even if you can’t talk to her, or if she did go through surgical menopause, given the sheer number of humans that experience this transition, there is guaranteed to be a cohort of women who have gone through the exact same challenges you have. In other words, YOU ARE NOT ALONE! (But yes, it still sucks. A lot.)


The changes that happen specifically to the vagina are known as vulvovaginal atrophy (VVA) or the genitourinary syndrome of menopause (GSM), if you want to get technical. These changes are a direct result of the loss of ovarian hormones, most importantly estrogen, which results in thinning, fragility, dryness, and loss of elasticity, among other things. The vagina is incredibly sensitive to estrogen, so it changes quite significantly when there isn’t any more of it circulating in your body. Even women who are taking hormone replacement therapy (HRT) experience these changes to some degree, because the low dose of estrogen in HRT doesn’t quite make up for what is lost when your ovaries become inactive.


Here’s a short list of some of the symptoms you might have:

· Vaginal dryness

· Pain with sex

· Loss of sexual desire and pleasure

· More difficulty achieving orgasm

· Itchiness/irritation

· Increased infections of the vagina and bladder (e.g., UTIs, yeast infections, bacterial vaginosis)

· Unusual vaginal odor

· Skin changes around the vagina

· Tightness of the opening of the vagina, making penetrative intercourse difficult or impossible

· Urinary symptoms such as urgency, leakage, and worsening incontinence


To summarize – it's a lot! But there is hope because your Women’s Health provider can talk to you about options to make your symptoms more manageable. While I can never promise to bring my patients back to their 20-year-old selves, you can enjoy significant improvement with a few simple interventions, some of which are even over the counter!


The first line for many women is simply vaginal lubricants or moisturizers, which can be purchased without a prescription. These include pH balancing solutions, lubricants, and pre-lubricant products that make the vagina feel more natural. It takes a bit of trial and error – the tissues down there are sensitive! - so you might need to try a few different brands before you find the right fit for you. I still recommend adding traditional lubricant to the mix to keep things as comfy as possible with sex. Some studies show that moisturizers are as effective for sexual symptoms as vaginal estrogen, which we’ll cover next, and is the first choice for pharmaceutical management.


Vaginal estrogen therapy, which is a much lower dose and therefore safer than systemic estrogen therapy, can be used in even high-risk women (in partnership with your oncologist, you can even use this if you’ve had breast cancer before!) Because the risks are so low, it is practically a no-brainer to try if you’re having even a handful of the symptoms above. Plus, it is exceptionally effective, and has the highest patient satisfaction rating of almost anything I prescribe in my practice! Nearly everyone who tries it feels at least a little bit better, and the benefits continue to evolve with longer-term use. Vaginal estrogen comes in several formulations, but the most common are vaginal tablets and vaginal creams. There are pros and cons to both types, and sometimes it takes trial and error to figure out the best choice for you. As I like to say, there is no such thing as one size fits all in medicine!


There are several confounding factors to consider here, which is why it’s always a good idea to talk to your provider directly. Prolapse, which is when your pelvic organs lose some support and start to “fall down”, can affect the success of both moisturizers and vaginal estrogen. Urinary incontinence is also a complicated matter (see my last post on this!) There can be specific anatomic challenges such as stenosis, or tightening/constriction, of the vaginal opening, which might need to be addressed with adjunct therapies such as dilators. Finally, there are some vaginal/vulvar inflammatory conditions, and even cancer (thankfully exceedingly rare), that can mimic atrophy and should be ruled out before starting therapy, or at least investigated further if you don’t experience improvement.


As always, we are here to help. Your Women’s Health provider’s goal is to make you feel comfortable enough in your own (vaginal) skin to live a happy, healthy, and productive menopause!


P.S. For a great resource on menopause in general (because the effects of menopause are by no means isolated to your vagina!) check out the North American Menopause Society’s (NAMS) patient-friendly website: https://womenlivingbetter.org