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Vaginal Changes After Menopause

At different stages of life, the vagina adapts. Especially right before and after menopause, you may notice some significant differences in your vagina. Let’s look at some ways to maximize vaginal and vulvar comfort at these times of life. 

Menopause happens when the ovaries no longer release an egg each month and the menstrual cycle totally stops. 

This event happens after a natural decline in reproductive hormones, usually around 45–55 years of age. The exact timing of menopause varies based on personal factors like genetics, previous pregnancies, physical activity, and body weight. 

As you experience the changes of menopause, your monthly periods will eventually stop. According to the Stages of Reproductive Aging Workshop (STRAW +10), a few years before a person undergoes menopause, the length of the menstrual cycle becomes more irregular, leading to cycles that can be 60 days or longer. This time is known as the menopause transition or premenopause.

Menopause is a one-time event that is marked by a person’s final menstrual period. It becomes clear that this menstrual period was the final one only after 12 months without periods. It also signals the end of “perimenopause,” a term that means the time around menopause. Perimenopause begins at the menopausal transition and ends 12 months after the final menstrual period. 

The time after the final menstrual period is called postmenopause

Menopause occurs in a few different ways. Here are some of the most common:

  • Naturally around the age 45–58 years (About 5% of people have early menopause at ages 40–45)
  • Because of surgery to remove the uterus (hysterectomy)
  • In response to chemotherapy or radiation therapy
  • Due to primary ovarian insufficiency

One of the biggest changes of menopause is a decline in estrogen levels. This leads to certain symptoms, which people experience in a variety of ways. 

Some of the physiological changes around menopause can involve the following:

  • Weight gain – It’s normal to gain two to five pounds during the transition from premenopause to menopause. This happens due to the decline in estrogen levels. 
  • Hot flashes – Most people experience hot flashes, often with blushing and some sweating. 
  • Trouble sleeping – Hormonal fluctuations also make falling asleep difficult, resulting in insomnia.  
  • Mood swings – Hormonal changes can prompt moods that fluctuate between cheerfulness, sadness, and depression. 
  • Bone changes – Bone density can drop, increasing the risk of bone fractures.
  • Sex drive changes – A drop in estrogen lowers the sex drive (libido).
  • Memory issues – Menopause may affect memory, which can increase the risk of Alzheimer’s disease. 

Around the time of menopause, people also experience fatigue, depression, joint and muscle aches, headaches, a racing heart, vaginal dryness, vision changes, increased skin wrinkling, poor muscle strength, and bladder control issues.

Before menopause, estrogen keeps the vagina lubricated and maintains its elasticity. The lining’s thickness folds allow it to stretch with sexual intercourse and childbirth. 

With the significant drop in estrogen levels after menopause, the vagina often becomes thin, dry, and less elastic. This condition is medically known as atrophic vaginitis or vaginal atrophy. 

People who develop this condition may experience vaginal soreness, itching in and around the vagina, vaginal dryness and irritation, tightening or shortening of the vagina, urinary symptoms, vaginal discharge, chafing and burning, inflammation of the walls of the vagina, decreased vaginal lubrication during sexual activity, and/or more frequent yeast infections and urinary tract infections (UTI). All these symptoms can also cause pain and bleeding during sexual intercourse or vaginal penetration (a medical condition technically known as dyspareunia). 

Before menopause, the vagina is naturally acidic, but after menopause it becomes more alkaline, increasing the chance of UTIs. Low estrogen levels result in more UTIs and vaginitis in postmenopausal people.

For some people who experience discomfort with menopause, the desire for sexual intercourse declines. Vaginal symptoms can also contribute to changes in sex drive. 

In summary, vaginal changes around menopause vary from person to person. Often, they can include these signs:

  • Thinning, drying, and reduced elasticity of the vaginal lining
  • Decreased vaginal lubrication
  • Vaginal atrophy 
  • Discomfort during sexual intercourse 
  • Increased risk of  vulvovaginal tearing during intercourse
  • Smooth, thin external genitalia
  • Pelvic organ prolapses (bulges in the walls of the vagina)
  • Sparse pubic hair

Vaginal thrush

After menopause, the vagina’s increased dryness and declining acidity make it more vulnerable to certain infections. 

Vaginal thrush, also known as vulvovaginal candidiasis, is an infection caused by an overgrowth of yeast called Candida albicans. People with thrush experience soreness, itchiness, and vaginal discharge, which is often white (like cottage cheese), thick, and odorless. 

Thin vaginal lining

During the menopausal transition, declining estrogen levels have a big impact on the epithelium (a protective layer of cells which forms the internal covering of some organs). Lower levels of estrogen can prompt the walls of the vagina to thin, sag, and wrinkle. This happens as a result of the decline in production and repair of elastin and collagen, which support the vagina’s structure.

Vaginal dryness

Vaginal dryness can create discomfort for many postmenopausal people due to changing hormones. This sensation occurs naturally during the menopausal transition and postmenopause. 

Problems associated with having a dry vagina include narrowing and shortening of the vagina; reduced libido or sex drive; pain during sex; and vaginal itching, burning, or irritation.

Fluid changes

Some people may notice watery discharge or a vaginal odor during menopause. This is due to the vagina’s changing acidity level — also known as pH — following a decline in estrogen levels.

Pelvic pain

At perimenopause, small uterine growths known as fibroids commonly regress because of hormonal fluctuations.

Vaginitis

Vaginitis or inflammation of the vagina can be caused by a yeast or bacterial infection or irritation from scented soaps or other products. Symptoms include itching, vaginal discharge, burning, and inflammation of the vulva and vagina.

Vaginismus

Vaginismus is involuntary spasms or contractions of the tissues at the vaginal opening. People with vaginismus can also develop stinging sensations. This condition results from estrogen deficiency and vaginal atrophy, leading to pain during intercourse.

Based on your unique menopausal changes, several remedies are available for addressing vaginal dryness and atrophy. These treatment options include:

  • Vaginal lubricants and creams
  • Emollient products like jojoba oil, coconut oil, vitamin E suppositories, and aloe vera
  • Estrogen cream

Topical estrogen cream is specially designed to reduce the symptoms of vaginal dryness. By applying the cream directly to the vaginal area, you will absorb less estrogen than if you’d taken it in pill form. 

Examples of topical estrogen therapies include:

  • Vaginal ring – This flexible ring is inserted into the vagina. The release of estrogen from the ring relieves vaginal discomfort after menopause.  
  • Vaginal creams – These can be applied to the interior of the vagina. Estrogen in the cream enters the blood, which can relieve symptoms of vaginal atrophy and dryness.
  • Vaginal tablet – This tablet is placed into the vagina to replenish estrogen.
  • Vaginal moisturizers – These help moisten the vaginal lining.

Menopausal people undergo tremendous changes in their bodies, especially the vagina. A postmenopausal vagina can experience a condition called vaginal atrophy, leading to itching, burning, vaginal discharge, and pain. As the vagina’s lining thins, you may notice some discomfort during intercourse, a condition called dyspareunia. The vulva may also shorten around menopause, and you might experience less pubic hair.

If you’re interested in seeking help with these changes, lots of options are available. Your health care provider can recommend different remedies like vaginal lubricants and creams and topical estrogen to maximize your vulvar and vaginal comfort around menopause.

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Hess, Rachel et al. “The impact of menopause on health-related quality of life: results from the STRIDE longitudinal study.” Quality of life research: an international journal of quality of life aspects of treatment, care and rehabilitation vol. 21,3 (2012): 535-44. doi:10.1007/s11136-011-9959-7

Huang, Alison J et al. “Vaginal symptoms in postmenopausal women: self-reported severity, natural history, and risk factors.” Menopause (New York, N.Y.) vol. 17,1 (2010): 121-6. doi:10.1097/gme.0b013e3181acb9ed

Mitro, Susanna D., et al. “Chronic Vulvar Pain in a Cohort of Post-Menopausal Women: Atrophy or Vulvodynia?” Women's Midlife Health, U.S. National Library of Medicine, 9 June 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC5260822/.

Reiter, Suzanne. “Barriers to effective treatment of vaginal atrophy with local estrogen therapy.” International journal of general medicine vol. 6 (2013): 153-8. doi:10.2147/IJGM.S43192

Santoro, Nanette et al. “Menopausal Symptoms and Their Management.” Endocrinology and metabolism clinics of North America vol. 44,3 (2015): 497-515. doi:10.1016/j.ecl.2015.05.001

Santoro, Nanette. “Perimenopause: From Research to Practice.” Journal of women's health (2002) vol. 25,4 (2016): 332-9. doi:10.1089/jwh.2015.5556

Stuenkel, Cynthia A et al. “Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline.” The Journal of clinical endocrinology and metabolism vol. 100,11 (2015): 3975-4011. doi:10.1210/jc.2015-2236

Wysocki, Susan et al. “Management of Vaginal Atrophy: Implications from the REVIVE Survey.” Clinical medicine insights. Reproductive health vol. 8 23-30. 8 Jun. 2014, doi:10.4137/CMRH.S14498

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