Many women notice changes in their vagina and genital area after the menopause. These changes may include dryness and discomfort during sex.
The changes described above can occur without causing any symptoms or discomfort. However, some of the following symptoms may develop in some women. Vaginal dryness is a common (and usually treatable) cause of the following problems. However, these problems can also be caused by other medical conditions.
- Pain when you have 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.
- 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.
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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.
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.
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).
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.
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 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.
Dr Sarah Jarvis, 27th May 2021
Transvaginal laser therapy not recommended by NICE
The National Institute for Health and Care Excellence (NICE) has issued guidelines about the use of transvaginal laser therapy for stress incontinence and vaginal atrophy.
Transvaginal laser therapy involves inserting a laser-probe device into the vagina to apply laser energy to the vaginal wall. The theory is that the controlled heat damage stimulates the vaginal tissue, leading to new collagen production and greater elasticity. The procedure can be carried out as an outpatient without anaesthetic. It usually involves three sessions, 4-6 weeks apart.
NICE noted that there was no evidence of any short-term safety concerns for this procedure. However, because there is not enough evidence on long-term safety and effectiveness, they do not recommend this treatment except as part of a research trial.
Before the menopause (often called the change of life) the skin and tissues around your vagina are kept supple and moist by fluids and mucus. These are made by glands at the neck of your womb. The female hormone, oestrogen, affects these glands. Oestrogen also affects your tissues in and around your vagina, causing the lining of your vagina to be thicker and more elastic. Oestrogen stimulates the cells that line your vagina to produce glycogen. Glycogen is a compound which encourages the presence of helpful germs (bacteria) which protect your vagina from infections.
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. It is probably even more common than that, as many women are embarrassed or feel they do not want to trouble their doctor with these symptoms.
Further reading and references
Menopause: diagnosis and management; NICE Guideline (November 2015 - last updated December 2019)
Guidance on Diagnosis and Management of Urogenital atrophy or Genitourinary Syndrome of the Menopause; Primary Care Women's Health Forum (2017)
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)