The menopause symptom women don’t want to talk about

Hot flashes and sleepless nights may get more attention, but issues “down there” can be more uncomfortable and last longer than other menopause symptoms. Vaginal atrophy, or atrophic vaginitis, is a prime culprit that can result in painful itching and burning. It’s also a common cause of pain during intercourse. Most women will start to experience symptoms in perimenopause when there is a significant decline in estrogen. Up to 60 percent of postmenopausal women experience symptoms of vaginal atrophy, yet only about 30 percent seek treatment, meaning too many women are needlessly suffering.

“Vaginal atrophy really can have a significant impact on a woman's quality of life. It can prevent her from being able to sit comfortably, exercise, enjoy vaginal intercourse, and put her at increased risk of infections.  The constant pain can be annoying and irritating and cause an additional emotional burden of feeling like she is unable to enjoy simple things.” --Dr. Yashika Dooley, M.D.

Many women are embarrassed to talk about issues “down there,” even with their doctors. But here’s the thing, there are lots of treatment options, and unlike other menopause symptoms that tend to dissipate once you’re postmenopausal, vaginal atrophy doesn’t go away. “If you don’t treat it, it’s just going to get worse as you have less estrogen,” says Dr. Yashika Dooley, who has a sub-specialty in urogynecology. “It starts off as a small thing, but then it begins to affect so many areas of your life. It becomes all-encompassing, and you don’t want that.” The sooner you talk to your doctor or healthcare provider, the sooner you can alleviate the pain, stop thinking about your vagina, and get on with enjoying life.

What is vaginal atrophy?

When you hear the word atrophy, you may think of it in the context of muscles. If you don’t work out, your muscles will atrophy—or shrink and weaken. But atrophy doesn’t just apply to muscles. And when it comes to “down there”, vaginal atrophy is about the lining of the vagina.

“Before menopause, estrogen causes the layers in the walls of the vagina to be thick and elastic,” says menopause-certified gynecologist and Gennev Chief Medical Officer Rebecca Dunsmoor-Su, M.D. Ample amounts of collagen give the lining elasticity, and lots of hyaluronic acid and blood vessels bring in moisture. The cells in the walls of the vagina create glycogen. Because of the vaginal wall structure, the top layer of the wall regularly breaks away. This attracts good bacteria like lactobacilli which feed on the glycogen to keep the pH of the vagina low. A low pH creates an acidic environment that keeps away harmful bacteria and yeast and reduces your risk of infections.

Declining estrogen levels with menopause are the primary cause of vaginal atrophy. “All of these things that keep the vagina plump rely on the stimulus of estrogen,” says Dr. Dunsmoor-Su. Just like you may notice that your skin and hair are drier during this stage of life, things down there can get drier, too. The lack of estrogen reduces the production of moisture, collagen, and acid, making vaginal tissue thinner, less elastic, and more fragile. Many women notice increased discomfort or decreased sensation due to these changes, making sex painful and orgasms harder to achieve.

The decrease in estrogen that occurs with menopause leads to decreased blood flow and vaginal lubrication (vaginal atrophy). Vaginal atrophy ultimately leads to changes in the pH of the vagina. Lactobacilli can no longer survive, so other bacteria replace them, and these are sometimes not such “good guys,” increasing your risk of infections. These changes can also cause urinary issues, such as frequent urination, leaks, and infections. That’s why vaginal atrophy is often referred to as genitourinary syndrome of menopause, which encompasses both the vaginal and urinary tract changes that occur as estrogen levels decline.

Since estrogen levels fluctuate during perimenopause, you may not notice symptoms until you’re closer to menopause or postmenopausal when estrogen takes a nosedive. Women who’ve never had a vaginal birth are more likely to develop symptoms than women who have, although the reason why is unknown. Women who’ve entered menopause more abruptly due to surgery or cancer treatments also tend to have worse symptoms.

How to help prevent vaginal atrophy

While you can’t stop the decline of estrogen, you can control two common risk factors: smoking and a lack of sexual activity. Smoking can inhibit the effects of any estrogen that you still have. It also affects circulation, decreasing the flow of nourishing nutrients and oxygen to that area. Likewise, a lack of sex can have a similar effect. Sexual activity, with or without a partner, stimulates blood flow and can keep your vagina more elastic.

You can also take steps to avoid aggravating symptoms.

Ditch tight clothing. The restriction can make burning, itching, and pain worse. You also get less airflow, which can increase your risk of infections.

Wear cotton underwear. It’s more breathable to keep you drier and reduce your chance of an infection.

Skip scents. If you use any products down there, stick to unscented varieties. Perfumes, fragrances, and other chemicals can make symptoms worse.  The fewer and the more natural the products you use in your vaginal area, the better. And look for products that are pH balanced.

Don’t douche. It can further dry out your vagina and increase your risk of infection.

Sleep au naturel. When you sleep without underwear, there’s no rubbing, and the area can air out. “Having nothing irritating it for six to seven hours at night gives the tissues time to heal,” says Dr. Dooley.

Retire sanitary pads. If you need protection from urinary leaks, use incontinence liners. They wick away moisture and form a barrier to keep the skin drier than menstrual pads. Constant moisture against your skin can irritate like a baby’s diaper rash.

Eat more soy. Soybeans, tofu, soy milk, and flaxseeds are high in phytoestrogens, plant compounds that act like estrogen. Some research shows that eating foods high in phytoestrogens reduces vaginal dryness. Eating more soy may also help with other menopause symptoms like hot flashes.

How to treat vaginal atrophy

The strategies above can help ease some of the burning, itching, and pain associated with vaginal atrophy,and for some women, that will be enough to manage their symptoms. However, lifestyle changes don’t address the underlying structural and functional changes in the vagina as estrogen declines. Some women will need to address those issues to get relief. Here are some options your doctor or healthcare provider can offer you.

Moisturizers and lubricants

Depending upon the severity of your symptoms, using a combination of a vaginal moisturizer during the day and a lubricant when you’re having sex may solve the problem for some women. Here’s what to look for in these products.

  • Paraben free These chemicals are used as preservatives and can irritate.
  • pH balanced This will help to maintain the body’s natural chemistry, minimizing your risk of infections.
  • Water-based lubricants Avoid products with glycerin, numbing or warming properties, fragrance, and flavor, which may contain substances that can be irritating.

If you find products that work for you, use them like hand lotion, putting them on throughout the day. “If you have dry skin, you don’t just put lotion on once a day,’” says Dr. Dooley. “Whenever you notice the dryness, you put on more lotion. It’s not a big deal.” If your vagina is irritated, use moisturizer or lubricant anytime during the day. Do not use petroleum jelly inside of the vagina because it can increase your chances of a yeast infection.

Moisturizers and lubricants are only treating the symptoms, though. They don’t change the tissue in the vagina. So, if they aren’t providing enough relief or stop working, see your doctor or healthcare provider STAT! “It’s easy for doctors to fix, and there are lots of ways we can fix it,” says Dr. Dooley.

Hormone therapy

Topical estrogen is an effective treatment for many women and comes in various forms. “In terms of hormones, in my experience, treating the vagina directly is key to getting a good response,” says Dr. Dunsmoor-Su. Creams, suppositories, or vaginal tablets are used daily for a few weeks and then one to three times a week to maintain estrogen levels and manage symptoms. There’s also a vaginal ring that your doctor places in your vagina. All you have to do is have it replaced every three months. If other menopausal symptoms are also disrupting your life, your doctor or healthcare provider may suggest oral estrogen or an estrogen patch, depending on your medical history.

Laser therapy

There are several devices on the market, but the one with the most evidence to support it is the Mona Lisa Touch device. The theory behind the laser is that it stimulates cells in the vagina to start rebuilding and rehydrating the area. It’s like turning back the clock. The tissues become thicker. The pH is rebalanced so healthy bacteria can thrive. In studies that track patient outcomes (but don’t provide comparisons) they show up to 90% symptom relief, however comparative studies are less positive, and there is some question about effectiveness of this therapy.  Laser therapy may also help with incontinence and pain during intercourse. Three initial treatments spaced six weeks apart are required, followed by annual maintenance treatments. Unfortunately, insurance doesn’t cover laser therapy for vaginal atrophy. The cost is usually between $600 and $1,000 per treatment. If you choose to try laser therapy, there are a few important warnings:

  • Only see an experienced gynecologist who gives reasonable counseling about the procedure. They should not be promising perfection, they should be able to talk about the studies with you
  • DO NOT get this done at a spa or non-gynecologist facility. These are not vaginal experts, and most often are doing it for the money. They will not take your unique situation into account
  • Be reasonable in your expectations, it isn’t a miracle machine, just a tool in our armament for treating atrophy

Like so many menopause symptoms, the severity of vaginal atrophy can vary from one woman to the next. These changes can also affect you both physically, mentally, and emotionally, especially when you consider all the other changes going on in your body while you’re trying to juggle a busy life. The right doctor or healthcare provider—one who is menopause-trained—can help.

Gennev's board-certified OB/GYNS are menopause specialists, and can offer more solutions for the menopause symptoms you’re experiencing. They’ll make it easier for you to talk about embarrassing problems like vaginal atrophy. With the right help, support, and treatment, you’ll feel more comfortable, and more confident. Book your virtual visit now!

The information on the Gennev site is never meant to replace the care of a qualified medical professional.  Hormonal shifts throughout menopause can prompt a lot of changes in your body, and simply assuming something is “just menopause” can leave you vulnerable to other possible causes. Always consult with your physician or schedule an appointment with one of Gennev's telemedicine doctors before beginning any new treatment or therapy.


Michele Stanten

March 21, 2023

Medically Reviewed By

Dr. Rebecca Dunsmoor-Su

Chief Medical Officer

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