Many women notice changes in their vagina and genital area after the menopause and during the perimenopause, the period of time during which periods become less regular and hormone levels fluctuate. These changes may include dryness and discomfort during sex. The term genitourinary syndrome of menopause (GSM) is now commonly used to describe these symptoms when they occur during the menopause.
What is vaginal dryness?
Vaginal dryness is exactly what it says - dryness of the vagina and the tissues around it. It usually occurs after the menopause but can also occur when breastfeeding or due to some medical treatments.
How common is vaginal dryness?
It is likely that many women don't report vaginal dryness, due to embarrassment, but various studies have shown that somewhere between one-third and one-half of women experience vaginal dryness while they are going through the perimenopause and after the menopause.
Vaginal dryness symptoms
Symptoms of vaginal dryness include:
- Pain during sex. This may occur because your vagina is smaller, drier and less likely to become lubricated during sex compared with how it was before the menopause. Also, the skin around your vagina is more fragile and this can make the problem worse. If pain is ongoing then it might stop you from having regular sexual activity.
- Discomfort - if your vulva or vagina is sore and red.
- Vaginal discharge. There may be a white or yellow discharge. Sometimes this is due to an infection. Infection is more likely if the discharge is smelly and unpleasant.
- Itch. The skin around your vagina is more sensitive and more likely to itch. This can make you prone to scratching, which then makes your skin more likely to itch, and so on. This is called an itch/scratch cycle which can become difficult to break and can be distressing.
- Urinary problems. Vaginal dryness may contribute to various urinary problems. This is because of thinning and weakening of the tissues around the neck of your bladder, or around the opening for urine to pass (the urethra). For example, urinary symptoms that may occur include an urgency to get to the toilet and recurring urinary tract infections (UTI's).
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Causes of vaginal dryness
Before the menopause the skin and tissues around your vagina are kept supple and moist by fluids and mucus.
After the menopause your ovaries make less oestrogen. The lack of oestrogen leads to thinning of the tissues around your vagina and a reduction in the number of glands that make mucus. You may also lose some fat tissue from around the genital area. This may make the area also look slightly different to how it was before the menopause.
After the menopause at least half of women have some symptoms related to vaginal dryness. You are also more likely to experience symptoms as more years pass after your menopause.
Various cancer treatment can cause vaginal dryness. These include some drugs used for breast and other cancers, chemotherapy, radiotherapy and hormonal therapy. If the ovaries have to be removed as part of a cancer treatment then the woman will go into a sudden menopause and is likely to have vaginal dryness as part of that.
Vaginal dryness treatment
Not all women have all of the above symptoms. Treatment usually depends on which symptoms are the most troublesome. Because the problem is mainly due to a lack of oestrogen, it can often be helped by replacing the oestrogen in your tissues.
Vaginal oestrogen creams and other topical preparations
A cream, vaginal tablet or ring containing oestrogen is often prescribed. A vaginal tablet is a very small tablet that you insert into your vagina with a small applicator and can be prescribed or bought over the counter.
The ring is a soft, flexible ring, 55 mm across, with a centre that contains the oestrogen hormone. This ring releases a steady, low dose of oestrogen each day and it lasts for three months.
These preparations work to restore oestrogen to your vagina and surrounding tissues without giving oestrogen to the whole body. Usually the treatment is used every day for about two weeks, and then twice a week for as long as is needed. This treatment usually works well but the symptoms may come back sometime after stopping the treatment.
Occasionally a repeated course of using it daily for two weeks is needed. These preparations should not be used as additional lubrication during sex; lubricating gels should be used instead.
Note: the oestrogen creams may damage latex condoms and diaphragms; if you are using these types of contraception then it would be preferable either to use vaginal tablets or the vaginal ring.
This is a newer medication used to treat painful sexual intercourse due to menopausal changes. This medication is different from hormones. It works by acting like oestrogen in some parts of the body. Ospemifene is a type of drug known as selective oestrogen receptor modulators (SERMs). It is only used in women who cannot use vaginal oestrogen therapy.
Hormone replacement therapy
Hormone replacement therapy (HRT) means taking oestrogen in the form of a tablet, gel or patches. This is often the best treatment for relieving your symptoms, especially if you are experiencing other symptoms of the menopause. There are advantages and disadvantages of using HRT. Many women are concerned about the risk of breast cancer from taking HRT, but HRT generally makes cancers grow more quickly rather than causing them, and the absolute risk is very small - obesity is a much bigger risk factor. If you are thinking about HRT but are worried about this, talk to your GP, they may well be able to reassure you.
Vaginal lubricants and moisturisers
If vaginal dryness is the only problem, or hormone creams are not recommended because of other medical problems, lubricating gels or moisturisers may help. There are different water based lubricants which can improve the dryness during sexual intercourse. You can buy these from the pharmacy and your pharmacist should be able to advise you.
Vaginal moisturisers can work really well to improve the moisture in your vagina. These need to be used regularly.
Note: Vaseline® is NOT recommended as a lubricant. It is not smooth or slippery enough and it can break down the latex in condoms.
Your symptoms should improve after about three weeks of treatment. You should see your doctor if your symptoms do not improve, as sometimes these symptoms can be due to other conditions. It is also very important to see your doctor if you have any bleeding from your vagina if you are receiving hormone treatment.
Some private providers may offer transvaginal laser therapy for vaginal dryness. The National Institute for Health and Care Excellence (NICE) has looked into this and concluded that there is not enough evidence on its long-term safety and so it should only be used in the research setting.
When to see a doctor for vaginal dryness
If vaginal dryness is bothering you then you should see your GP - they will not be embarrassed and might well be able to prescribe something that can help you.
Dr Hazell is on the board of the Primary Care Women's Health Forum, a role that involves both paid and unpaid work.
Further reading and references
Menopause: diagnosis and management; NICE Guideline (November 2015 - last updated December 2019)
Weber MA, Limpens J, Roovers JP; Assessment of vaginal atrophy: a review. Int Urogynecol J. 2015 Jan26(1):15-28. doi: 10.1007/s00192-014-2464-0. Epub 2014 Jul 22.
Faubion SS, Sood R, Kapoor E; Genitourinary Syndrome of Menopause: Management Strategies for the Clinician. Mayo Clin Proc. 2017 Dec92(12):1842-1849. doi: 10.1016/j.mayocp.2017.08.019.
Transvaginal laser therapy for urogenital atrophy; NICE Interventional procedures guidance, May 2021
Vulvovaginal atrophy (VVA) Treatment Comparison Table; Primary Care Women's Health Forum,