When it comes to ageing, few body parts go through quite so much over the course of an average lifetime as the humble vagina. Changes to collagen production and hormone levels bring about natural changes from puberty through to the menopause, which can, of course, be exacerbated by sex, pregnancy, childbirth, and even certain cancer treatments.
So what kind of changes can you expect, and what can you do to keep your vagina healthy throughout your life?
Incontinence, or the involuntary leakage of urine, is a common issue that can affect women of all ages, but it does become more common with age. Many women begin to notice it during pregnancy or after vaginal delivery, because of the stress childbirth places on the pelvic floor muscles and urethral sphincter.
"The vagina is a nice big thick tube in the middle of our bodies, so it's supporting structures above it as well, like the urethra. As your vagina ages, and the structure is strained by traumas like childbirth, that entrance to your wee tube goes from being round to quite long and pouty," explains urology nurse Emma Soos, the managing director of The Women's Health Clinic.
These anatomical changes can also put you at increased risk of urinary tract infections (UTIs), but can often be treated with lifestyle changes.
"Women are encouraged to first try self-help options to ease their symptoms, such as losing weight, cutting down on caffeine and alcohol, practising pelvic floor exercises and bladder training," says Dr Swati Jha, a spokesperson for the Royal College of Obstetricians and Gynaecologists (RCOG). "If self-help measures aren't able to treat incontinence, medication and surgery may be considered," she adds.
The vagina also changes according to fluctuating hormone levels, Soos explains. "If you're pregnant it becomes a lot thicker - more dense, because it's got a great blood flow," she says. "If you're overweight, or if you lose weight, then changes to the structure can happen as well - because there's quite a lot of oestrogen in fat."
Likewise, when oestrogen levels drop - as in menopausal women - the structure changes again, and can lead to atrophy, or persistent vaginal dryness. "The drop in oestrogen leads to a reduction in the amount of vaginal discharge produced, and a thinning of the vagina's walls," explains Nick Panay, a spokesperson for the RCOG.
This coincides with a natural slowing down of collagen production, which makes the vaginal tissue less elastic, drier, and more crepey - not dissimilar to the wrinkles you get on your face as you age, Soos explains.
54-year-old Sara developed atrophy after receiving intensive treatment for oestrogen receptor-positive breast cancer.
"My particular cancer was feeding off oestrogen so, as well as having the menopause I would have had anyway, the menopausal symptoms were intensified by the cancer treatment. They were increased still further by the fact I was having hormone treatment to bring my oestrogen levels from quite high down to zero," she says.
"It was absolutely horrendous; I was getting six or seven hot flushes every hour, I couldn't sleep, and it got to the point where I actually thought I was never going to have sex again. I couldn't even put the tip of my little finger a quarter of an inch inside my vagina; it was just too painful."
In most cases, atrophy can be easily treated - for example, by using lubricants or vaginal moisturisers before sex. If it's not too uncomfortable, having sex or masturbating will also help to keep the area moist and supple. However, if your symptoms can't be controlled in this way, Panay explains, you may be prescribed vaginal oestrogen - a hormone treatment available in the form of pessaries, creams or vaginal rings.
The use of vaginal oestrogen in women with a history of oestrogen-positive breast cancer is a contentious issue; the American College of Obstetricians and Gynecologists recommends working with the woman's oncologist to decide if such a treatment is appropriate. The College makes the point that: "Data do not show an increased risk of cancer recurrence among women ... who use vaginal oestrogen to relieve urogenital symptoms". But they recommend that it be considered only in women who have failed to respond to non-hormonal treatments.
In Sara's case, having tried all the conventional methods, it was a private CO2 laser treatment, called Nu-V®, at The Women's Health Clinic, that got her back to 'jumping on my husband!'
Such a procedure is not recommended by the NHS as there's not yet enough evidence to confirm its effectiveness. And it currently costs around £1,000 for a complete treatment plan. The laser works by creating a microinjury, which, Soos explains: "triggers a cascade of wound healing, so the body's natural wound healing mechanism kicks in." In addition, she adds, the laser delivers a small amount of heat into the vaginal tissue. "Those two things have very different pathways, but the end result is new collagen growth."
As well as reviving her sex life, Sara says her vagina feels plumper, less painfully sensitive, and her recurrent UTIs have stopped.
"The vaginal tissue feels thicker, plump, healthy, more lubricated and more responsive," she explains. "It's made such a difference to my self-confidence - being able to go to the loo, have a bath, or have sex with my husband, without worrying about being really sore and dry."
Finally, prolapse is a condition where one or more of the pelvic organs - such as the uterus, bladder or rectum - slip down from their normal position and bulge into the vagina.
"The most common cause is a weakening of the pelvic floor," says Jha. "This can be caused by pregnancy, childbirth, family history, certain medical conditions that affect the collagen, increasing age - particularly the menopause - or constipation, hysterectomy, or being overweight."
Prolapse isn't life-threatening, but can be uncomfortable and affect your quality of life. Again, it can often be improved by pelvic floor exercises and lifestyle changes - such as stopping smoking, weight loss, and exercise. If you are still suffering despite these changes, other options include vaginal pessaries to hold the vaginal structures in place, hormone replacement therapy (including topical treatment) or surgery.
It is important to know that as a result of serious and well-recognised safety concerns, the National Institute for Health and Care Excellence (NICE) updated its guidance about surgery for prolapse in December 2017. They no longer recommend that transvaginal mesh (the insertion of mesh designed to provide added support after prolapse surgery and reduce the risk of recurrence) should ever be used for prolapse except in specific research circumstances.
General vaginal health
Often, simply knowing what to expect helps women feel more prepared to cope with these natural changes. The Women's Health Clinic recently launched its 'Am I normal?' campaign, to increase knowledge and education about the diversity and complexity of vaginas - both in terms of their appearance and the problems they present.
Besides regularly practising your pelvic floor exercises, there are several simple steps you can take to keep your vagina healthy as you get older.
"It's important to remember that the vagina is designed to clean itself with natural secretions called discharge, so avoid douching or using perfumed soaps, gels or antiseptics, as these can affect the healthy balance of bacteria and pH levels in the vagina and cause irritation," says Dr Vanessa Mackay, a consultant obstetrician and spokesperson for RCOG.
Likewise, she adds: "Pubic hair offers a natural barrier to keep things clean, decrease contact with viruses and bacteria, and to protect the tender skin of the area. Shaving your pubic hair puts you at higher risk of contracting STIs, and also irritates the hair follicles left behind."
While you're still menstruating, use whichever products make you most comfortable, and remember to change tampons regularly to avoid toxic shock syndrome (TSS) - a rare but life-threatening bacterial infection. Wearing cotton underwear and sleeping naked can help the area to breathe, and prevent yeast infections like thrush, while practising safe sex will protect you from STIs.
Finally, Mackay says: "Attend your cervical screening appointment (smear test), and don't ignore any abnormal symptoms, however embarrassing." These could include bleeding between periods, changes to your discharge, itching outside the vagina, or pain in the pelvis or tummy.