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The Menopause Symptom No One Talks About

Menopause causes a dry vagina? Why has no one ever told me this?  

This is a common question I am frequently asked in my clinic. Women do not have adequate education on menopause in general, let alone what happens “down there” with menopause.

Technically, a woman is in menopause if a year has gone by without a period. Women who have had a hysterectomy or use a form of birth control where you don’t have periods might have more trouble determining their menopausal status. The average age of menopause in the United States is 51, with the most common age range of 48-55. Three million women experience menopause each year. A 2005 study estimated that as many as 85% of postmenopausal women have experienced a menopause-related symptom in their lifetime.

Prior to menopause, women can experience symptoms of “perimenopause.” The ovaries are in a time of change.  Much like puberty, there is a complete hormonal shift. The ovaries usually don’t stop producing estrogen all at once but in more of a start/stop pattern. During this time, women may have irregular menstrual cycles and occasional hot flashes followed by a month or two of regular cycles and no other symptoms. When the estrogen levels are fluctuating and lowering, common side effects are sleep disturbances, hot flashes, anxiety and depression.  For many women, these symptoms can be extremely disruptive. When the ovaries officially stop producing estrogen, eggs stop releasing from the ovaries, and the lining of the uterus stops shedding (no more periods!).

Before menopause, estrogen supports not only fertility, but also facilitates excellent blood flow and healthy collagen to the vagina.  After menopause, loss of this support can be very uncomfortable. Women may experience vaginal dryness and a new onset of discomfort or even pain with intercourse. Other changes include narrowing and shortening of the vagina, decreased ability to stretch, and thinning of the skin of the vulva. 

In medicine, we call these changes Genitourinary Symptoms of Menopause (GSM). This term describes the various menopausal symptoms and signs including not only genital symptoms (dryness, burning, and irritation), and sexual symptoms (lack of lubrication, discomfort or pain, and impaired function), but also urinary symptoms (urgency, dysuria, and recurrent urinary tract infections).  

Some women notice these vaginal changes way before they enter menopause, as estrogen starts to decrease in the early 40s. In addition, some oral contraceptive pills essentially cause an estrogen blockage in the vaginal tissues, leading some younger women to experience these GSM vaginal and vulvar skin changes that can make intercourse undesirable and painful. 

So what is a woman to do? We can’t stop the clock but we can understand what is happening and take measures to limit the discomfort from the hormone changes. There are several options.

  1. Vaginal lubricants. These can be for daily use, are mild and can come in cream/liquid or tab/suppository “pearls”. Vmagic is one brand.  
  2. Sexual lubricants. Water-based lubricants get soaked into dry skin immediately and tend not to last well for post-menopausal vulvas. A silicone lubricant does not get absorbed by the skin and provides a much longer lasting experience to improve dryness with sex. Uberlube is a great example of a silicone lubricant.  
  3. Vaginal estrogen or DHEA. These are prescription products so you need to see your primary care provider for this. Vaginal estrogen has been around for decades and comes in rings, creams and tabs. This keeps the vulva moist, soft and treats painful sex caused by GSM. Some oncologists prefer that their patients stick with non-hormonal options, so if you have a history of breast cancer discuss this further with your health care team.
  4. Vaginal lasers. Lasers started out on the face and body then moved “downstairs” over five years ago. They work by increasing blood flow and collagen to the tissues.  Although not FDA approved for the specific indication of dryness, they do seem to work well. For our Northern neighbors, Health Canada (Canada’s FDA) has approved a laser for the treatment of the symptoms of GSM in peri and post-menopausal women. Let’s hope the American FDA catches up soon.  
  5. Systemic estrogen. This can relieve GSM symptoms but the vulva is the last stop on the train of importance for estrogen, so I see many women on systemic (patch or pill) hormones who still need to consider options 1-4. That said, in many women, hormone supplementation can help. Ask your doctor or health care provider if it is right for you.

If menopause has left your vagina dry, and your sex uncomfortable, you are not alone! This is extremely common and easily treatable. Please use this information to start a conversation with your health care team to improve your health and keep your sexy alive!

Dr. Casperson is a urologist specializing in female urology. In her free time she podcasts at You Are Not Broken


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