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Vaginal Changes and Problems During Menopause

Changes in the vagina pre- and postmenopause are quite significant. Maximum vaginal and vulvar comfort becomes crucial at this time of women's lives, and there are several ways to prevent vulvovaginal atrophy/genitourinary syndrome of menopause.

Menopause happens when the ovaries no longer release an egg on a monthly basis and the menstrual cycle totally stops. Some of the physiological changes during menopause include:

  • An average woman gains from 2 to 5 pounds during the transition from perimenopause to menopause. This happens due to the decline in estrogen levels during menopause. 
  • Most women during menopause experience hot flashes, often with blushing and some sweating. Some other changes that take place at the time of menopause include irregular or skipped periods, fatigue, depression, irritation, joint and muscle aches, headaches, racing heart, vaginal dryness, itching and burning, weakening in vision, increased skin wrinkling, poor muscle power, and bladder control problems.
  • Hormonal fluctuations during menopause also make it difficult to fall asleep at night resulting in insomnia.  
  • Different moods that fluctuate between cheerfulness, sadness, and depression. 
  • Bones start becoming brittle increasing the risk of osteoporosis. Bone density decreases with menopause increasing the risk of bone fractures
  • A drop in estrogen during menopause lowers the sex drive or libido.
  • Menopause is also said to affect memory increasing risk of Alzheimer’s disease. 

Before attaining menopause, the vagina is well supplied with the hormone called estrogen which keeps it lubricated and maintains its elasticity. There is no change in the vaginal walls and lining. The lining is thicker and has more folds that allow it to stretch with sexual intercourse and childbirth. 

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  • vaginal lining becomes thin, dry, less elastic and less flexible
  • declined vaginal lubrication
  • vaginal atrophy – avoiding sexual intercourse because of pain and discomfort
  • vaginal lining has fewer folds due to the decline in estrogen levels
  • dry, fragile vulvovaginal tissues are susceptible to bleeding, injury and tearing during intercourse
  • sparse pubic hair
  • smooth, thin external genitalia
  • pelvic organ prolapses (bulges in the walls of the vagina)

Menopause is the time in a woman’s life (aged 45 and 55) when there is a natural decline in reproductive hormones and her ovaries no longer release eggs.

Some other changes during menopause include permanent termination of monthly periods. A woman is postmenopausal when she has not had a period for nearly twelve months or longer.

Menopause occurs in the following ways:

  • As natural aging in women in the age group of 45-55 years
  • As a result of hysterectomy (removal of the uterus)
  • Chemotherapy and radiation therapy
  • Primary ovarian insufficiency

One of the biggest changes that accompany menopause is the decline in estrogen levels. With the significant drop in estrogen levels after menopause, the vaginal tissues become thin, dry and less elastic. This condition is medically termed as atrophic vaginitis or vaginal atrophy. 

Some of the changes that happen due to this condition include vaginal soreness, itching in and around the vagina, vaginal dryness and irritation, tightening or shortening of the vagina, distressing urinary symptoms, vaginal discharge, chafing and burning, inflammation of the walls of the vagina, decreased vaginal lubrication during sexual activity, and/or more frequent infections in the area, such as yeast infections and UTI. All these symptoms also cause pain and bleeding during sexual intercourse or vaginal penetration (a medical condition technically known as dyspareunia). 

A normal vagina before menopause is naturally acidic, but after menopause it becomes more alkaline, increasing vulnerability to UTI. Low estrogen levels result in more UTIs and vaginitis in postmenopausal women.

After menopause, the urge for sexual intercourse declines due to the expectation of pain. Much more complex change is a decline or significant lowering of the libido or the sex drive. Vaginal symptoms are a contributing factor to decreased sex drive and other associated life stresses including changes in your relationship with your spouse or partner. 

Some other vaginal changes after menopause include:

  • Vaginitis — this is also termed as inflammation of the vagina caused by a yeast or bacterial infection or by irritability from soaps or hygiene items. Symptoms include itching, vaginal discharge, burning, and inflammation of the vulva and vagina.
  • Vaginismus — involuntary spasms or contractions of the tissues at the vaginal opening Vaginismus is painful causing stinging sensations. It is a result of painful intercourse caused by estrogen deficiency and vaginal atrophy. 

Vaginal thrush, also known as vulvovaginal candidiasis, is defined as an infection caused due to an overgrowth of yeast named Candida albicans. The symptoms include soreness, itchiness and discomfort. It is very unpleasant and uncomfortable and causes vaginal discharge, often white (like cottage cheese) which is thick and usually odorless. An increased vulnerability to infection is another possibility with dry vagina after menopause. As the acidity of the vagina declines, the vagina loses its potential to fight vaginal infections like Candida Albicans (thrush) and other microbes.

While transitioning from pre-menopause to menopause, declining estrogen levels have a big impact on the skin. Lower levels of estrogen make you prone to vaginal mucosa thinning, sagging, and wrinkling. Reduced estrogen levels result in declined production and repair of elastin and collagen in the dermis of the skin.

Vaginal dryness can be a cause of discomfort for many postmenopausal women. It is an uncomfortable and often painful condition that occurs naturally during perimenopause and postmenopause. There is a sharp decline in estrogen during menopause which causes the dryness. It is a hallmark sign of the GSM (genitourinary syndrome of menopause), also known as atrophic vaginitis or vaginal atrophy. Problems associated with having a dry vagina include; narrowing and shortening of the vagina, reduced libido or sex drive, pain during sex, vaginal itching, burning, discomfort and irritation.

Many women during menopause notice a smelly, watery vaginal discharge that can cause you distress. A change of pH in the vagina due to the decline in estrogen levels and fluctuating hormones can result in vaginal odor.

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During perimenopause and menopause, uterine fibroids commonly regress because of the decline in levels of hormone-like estrogen.

Several treatments and natural remedies are available for addressing vaginal dryness and atrophy. Treatment options include:

  • Vaginal lubricants and creams
  • Products like Astroglide, K-Y jelly, Sliquid, jojoba, coconut oil, Vitamin E suppository, and Aloe Vera can help moisten the vaginal area. 
  • Topical estrogen cream

Topical estrogen cream can reduce the symptoms of vaginal dryness. The cream is applied directly to the vaginal area to get relief from the symptoms. This treatment involves much less absorption of estrogen in comparison to estrogen taken as a pill. 

Examples of topical estrogen therapies include:

  • Vaginal ring. It's a flexible ring inserted into the vagina with an intention to release estrogen into the tissues. The release of estrogen from the ring relieves vaginal discomfort after menopause.  
  • Vaginal creams. These can be applied to the interior of the vagina. Some of the estrogen in the cream is absorbed into the blood which raises estrogen levels in the blood much the same as estrogen pills. These creams are an effective and well-tolerated therapy for vaginal atrophy and vaginal dryness in comparison to a placebo.
  • A vaginal tablet. In this treatment, a tablet is placed into the vagina. It helps replenish estrogen lost due to menopause.
  • Vaginal moisturizers. These are used to keep vaginal tissues moist and healthy.
  • Ospemifene. This is a selective estrogen receptor modulator (SERM) medication consumed orally and helps in the treatment of vaginal atrophy. Please note – this medication is not recommended for women who have had breast cancer or those who are at a high risk of breast cancer.
  • Dehydroepiandrosterone (DHEA). It's a nightly vaginal suppository for the treatment of painful sex in menopausal women.

Menopausal and postmenopausal women undergo tremendous changes in their bodies, especially the vagina. A postmenopausal vagina can face a condition called vaginal atrophy. This condition accompanies itching, burning, vaginal discharge, and pain. The thin vaginal lining caused during menopause causes pain during intercourse, a condition called dyspareunia. As far as vulva is concerned, some changes that occur during and post-menopause include loss of pubic hair and the shrinking of the labia size.

This may all sound pretty awful, but the good news is that there's plenty of help available. Several remedies and treatments like vaginal lubricants and creams and topical estrogen are available to maximize vulvar and vaginal comfort during menopause.

Goldstein, I., Dicks, B., Kim, N. N., & Hartzell, R. (2013). Multidisciplinary overview of vaginal atrophy and associated genitourinary symptoms in postmenopausal women. Sexual medicine, 1(2), 44-53.

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Huang, A. J., Moore, E. E., Boyko, E. J., Scholes, D., Lin, F., Vittinghoff, E., & Fihn, S. D. (2010). Vaginal symptoms in postmenopausal women: self-reported severity, natural history, and risk factors. Menopause (New York, NY), 17(1), 121.

Kingston, A. (2009). The postmenopausal vulva. The Obstetrician & Gynaecologist, 11(4), 253-259.

Mitro, S. D., Harlow, S. D., Randolph, J. F., & Reed, B. D. (2016). Chronic vulvar pain in a cohort of post-menopausal women: Atrophy or Vulvodynia?. Women's midlife health, 2(1), 4.

Reiter, S. (2013). Barriers to effective treatment of vaginal atrophy with local estrogen therapy. International journal of general medicine, 6, 153.

Santoro, N., Epperson, C. N., & Mathews, S. B. (2015). Menopausal symptoms and their management. Endocrinology and Metabolism Clinics, 44(3), 497-515.

Santoro, N. (2016). Perimenopause: from research to practice. Journal of Women's Health, 25(4), 332-339.

Stuenkel, C. A., Davis, S. R., Gompel, A., Lumsden, M. A., Murad, M. H., Pinkerton, J. V., & Santen, R. J. (2015). Treatment of symptoms of the menopause: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 100(11), 3975-4011.

Wysocki, S., Kingsberg, S., & Krychman, M. (2014). Management of vaginal atrophy: implications from the REVIVE survey. Clinical Medicine Insights: Reproductive Health, 8, CMRH-S14498.

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