Understanding Vaginal Changes
Changes to the vagina during perimenopause are one of the key symptoms of the Genitourinary Syndrome of Menopause (GSM), which is a chronic progressive condition that can result in changes to the vagina, to your normal sexual behaviours, and to your urinary system. Vaginal dryness and pain are symptoms of a condition called vaginal atrophy (atrophic vaginitis) that occur as a result of lowered estrogen levels. [1]
The vagina is sensitive to changes in estrogen levels because it has an abundance of estrogen receptors, which are basically docking stations for estrogen, allowing the hormone to communicate with the cells and tissues in your vagina and vulva. During the menopausal transition, the state of the vagina often changes because there is less estrogen available to send the messages that maintain vaginal health.
The noticeable impacts of vaginal changes for women include:
- Vaginal dryness, which is experienced by up to 93% of peri- and post-menopausal women.
- Burning, itching, and irritation – experienced by up to 63% of peri- and post-menopausal women
- Spotting (small amounts of blood when you wipe after urination or in your underwear)
- Reduction of vaginal lubrication
- Changes in the look and amount of vaginal discharge
- Changes in vaginal odour
Normal vaginal function includes all of the following:
Discharge
Discharge
- All females will experience vaginal discharge, which is the name for any substance that exits the body through the vagina. The cells in the muscular tissue lining the vagina secrete mucus, which makes the walls slippery. This mucus also protects against bacteria and yeast overgrowth.
- Normal daily vaginal discharge includes a small amount of vaginal lubricants, cervical mucus, and sexual arousal fluid. If you are experiencing excessive amounts of discharge, or discharge with a strong odour or a different colour than normal, see your healthcare provider as these can be signs of other issues, including infections, that need to be immediately treated. [2]
Odor
Odor
- Normal vaginal odour is mild and may occasionally be so mild that there is no apparent smell at all. While this does vary from individual to individual, strong odours from the vagina are not typical. If you do notice a change in the odour ‘down there’, especially if you have other vaginal symptoms such as itching, burning or changes to your normal discharge, talk to your healthcare provider, as you may have an infection or other condition that needs treatment.
- Vaginal odours are known to vary throughout the menstrual cycle, meaning there is a hormonal component to them. If you notice a change in your vaginal odour, it could be caused by a number of other factors including your changing hormones or even your diet. [3]
Dryness
Dryness
- Estrogen ensures that the cells in the vagina are elastic and that the walls of the vagina are thick and healthy. When estrogen levels drop, the walls of your vagina can become dryer than your normal amount of lubrication.
- Perimenopause is not the only possible cause for lowered estrogen levels. If you have recently experienced childbirth, are breastfeeding, undergoing cancer treatment, or experiencing any condition that requires estrogen-blocking drugs, you may also experience vaginal dryness. In these cases, when estrogen levels return to normal, the vaginal atrophy will correct itself.
- In the case of perimenopause, estrogen levels will continue to drop until they stabilize at a lower level permanently in postmenopause, meaning that most women will experience vaginal atrophy as they age.
- Non-hormonal factors can also cause vaginal dryness. The most common causes are some cold and allergy medications, some antidepressants, or a condition called Sjögren syndrome. This is an autoimmune condition resulting in a dry mouth and eyes, and on some occasions, vaginal dryness. [1] [4] [5] [6] [7]
Pain
Pain
- Changes in the vagina during perimenopause can also result in pain, including pain during sex, after orgasm, and/or during urination, as well as other uncomfortable sensations such as burning and itching. Refer to Sexual Changes for more detailed information on pain during sex, and Urinary System Changes for more detailed information on pain during urination. [8] [9]
Women may be very reluctant to speak up and act on vaginal issues due to embarrassment and negative feelings about aging. However, these are conditions that can often be treated easily at home and with the help of a medical practitioner.
Self-care for Vaginal Changes
To address changes to your vagina, including vaginal atrophy resulting in vaginal dryness, at home you can:
- Use over-the-counter water-based lubricants to hydrate the walls of your vagina. This can also help reduce vaginal infections.
- Stimulate the muscles of and increase the blood flow to the vaginal wall with vaginal sex and masturbation, as this helps keep your vaginal tissues healthy.
- Avoid vaginal intercourse when experiencing pain and dryness, as this can result in tearing delicate tissues and may lead to infections.
- Never ‘clean’ or deodorize your vagina by inserting or using any herbal products, douches, deodorants, chemicals, soaps, cleansers, perfumed products, or steam. Your vagina is an internal organ, and it is self-cleaning. Your vagina has a natural balance of conditions, including pH (acidity) and natural bacteria. Using external products will disturb this balance, likely causing any odours, discharge or any other unpleasant symptoms such as irritation and burning will get worse . Your natural and normal vaginal secretions and environmental conditions (including temperature) are the only safe ‘cleansers’ you need.
Seek medical care if you notice increasingly strong odor, increased vaginal pain, or changes in discharge. [5] [6] [10]
Statistics
Therapy for Vaginal Dryness and Urine Leakage
At age 40 find a reliable, educated primary care provider familiar with recognizing and treating the symptoms of perimenopause and menopause. The North American Menopause Society provides a list of menopause practitioners here.
The effects of menopause-related vaginal thinning and dryness can often be helped by using over-the-counter (non- prescription), preferably water-based lubrication products, gentle Kegel exercises, and safe and effective HT with estrogen. [11]
Lubrication Products
Lubrication Products
Using over-the-counter (non-prescription) water-based lubrication products:
Lubricants are typically applied just before intercourse and reduce vaginal pain. Check to see if the product contains any petroleum (like petroleum jelly) or coconut oil. If you are in the menopausal transition there is still a chance of pregnancy, petroleum-based products or lubricants containing coconut can break down latex used in condoms. Only water- and silicone-based lubricants can be used with latex condoms without risking breakage.
Kegel Exercises
Kegel Exercises
Strengthen your pelvic floor muscles through pelvic floor muscle training, also known as Kegel exercises. Make sure your Kegel exercises are done correctly as they can otherwise cause some harm. Talk to your medical care provider or find a physiotherapy that specializes in pelvic floor exercises to get a pelvic floor muscle assessment and instructions on the correct form to practice Kegels at home.
Vaginal Estrogen
Topically Applied Hormone Therapy (HT)
If other causes for your vaginal dryness are ruled out, your healthcare provider may prescribe topically (locally) applied hormone therapy (HT). Locally applied HT can also help to reduce the incidence of urinary tract infection (UTI).
There are three methods of applying vaginal estrogen:
The Science
The vagina its own self-contained system. Like your intestines, the vagina has its own microbiome made up mostly of probiotic (or ‘good’) bacteria and some yeast cells. When the vaginal microbiome is disrupted, infections occur. For instance, bacterial vaginosis, the most common bacterial infection, is caused by an overgrowth of ‘bad’ bacteria. Yeast infections are the second most common vaginal infection, caused by an imbalance of yeast cells to probiotic bacteria.
The vagina is healthiest at a moderately acidic pH level between 3.8 and 5 on the pH scale because it keeps bacterial and fungal infections from starting. The pH scale measures the acidity of a substance. If a substance isn’t acidic, it is basic. This diagram shows the range of substances from extremely acid to extremely basic. The probiotic bacteria living in the vagina produce lactic acid and hydrogen peroxide, which together create the acidic pH levels.
Download
Keeping the vaginal microbiome healthy
The vaginal microbiome can be damaged, often leading to infections. For example, using any cleaning or perfumed products in the vagina can alter its pH and reduce the healthy probiotic bacteria. If you are prescribed antibiotics, these will kill all bacteria, not just the bad bacteria, so using them will affect the vaginal microbiome. However, the self-contained system of the vagina is able to rebalance itself without supplements or special treatment.
Probiotics are foods or supplements that contain live microorganisms intended to maintain or improve the “good” bacteria (normal microflora) in the body. Prebiotics are foods (typically high-fiber foods) that act as food for human microflora.
Healthcare providers do suggest that eating fermented foods (which provide probiotic bacteria) such as yoghurt, kefir, kimchi, pickles or kombucha can help the microbiome establish itself faster. These probiotic foods contain live probiotic bacteria.
Eating foods rich in prebiotics can also help the vagina restore its natural microbiome. Food containing prebiotics include leeks and onions, oats, soybeans, asparagus, bananas and garlic. Prebiotic foods contain substances that are ‘food’ for probiotic bacteria.
Genitourinary Syndrome of Menopause (GSM)
If you are experiencing vaginal dryness, you may also experience a dry and irritated vulva due to having less moisture overall up inside the vagina. As well, you may also have to urinate more frequently and could have repeated urinary tract infections (UTIs). This group of symptoms is common during menopause, and it is called the genitourinary syndrome of menopause (GSM). More information on GSM is provided below and on the GSM Symptom page. [1] [7]
Changes to the vagina usually occur at the same time as changes in the urinary tract, so they have recently been combined into a single category – genitourinary syndrome of menopause (GSM). GSM covers a variety of changes to the genitourinary tract – particularly the urethra, vagina and vulva. Vaginal atrophy and urinary incontinence (UI) are the most common symptoms of GSM, affecting 40-50% of midlife and aging women. [6] [9]
Signs and Symptoms of GSM
Vagina
▢ vaginal dryness
▢ irritation / burning / itching
▢ changes to vaginal discharge
▢ thinning / graying pubic hair
▢ vaginal / pelvic pain and pressure
▢ vaginal prolapse (top of the vagina falling into the vaginal canal)
Urinary System
▢ painful urination
▢ urgency incontinence
▢ stress incontinence
▢ frequent / recurring urinary tract infections
▢ urethral prolapse
Sexual
▢ painful sex
▢ bleeding after sex
▢ decreased orgasm
▢ loss or reduction in libido
▢ pain after orgasm (dysorgasmia)
Yes and No.
There are natural treatments (such as drinking cranberry juice and urinating frequently) that may help either the vaginal or the urinary symptoms. However, the cause of GSM is reduced levels of estrogen, so it is unlikely that the improvements will be maintained. As estrogen levels continue to decline, the condition will continue to develop.
It may, but only if you are using Menopause Hormone Therapy (MHT) to increase your estrogen levels. The cause of GSM is reduced levels of estrogen due to perimenopause and that is irreversible.
MYTH
The inside of your vagina is a carefully balanced natural environment with a unique microbiome (good bacteria and other microorganisms, just like in your gut) that works to keep it healthy. It is also a very sensitive area that can be easily harmed. Steam is very hot (by definition!) and it can easily burn the vulva and the interior of the vagina (ouch!). The herbs that are used in the steam or rinse can also cause problems if they create an imbalance in the microbiome that causes bacterial or yeast infections. There is also a possibility that bacteria can get introduced into the vagina from the equipment being used. Not recommended.
If your vaginal dryness is caused by low estrogen levels, your healthcare provider may prescribe topical estrogen therapy. There are three methods of applying vaginal estrogen:
- Ring: You or your doctor can insert a soft, flexible ring into your vagina. It releases estrogen directly to the vaginal tissues. The ring lasts about three months so it will need to be replaced regularly.
- Tablets: These tablets are inserted into your vagina with a disposable applicator.
- Cream: The cream is inserted into your vagina using an applicator.
There are over-the-counter vaginal moisturizers as well. Speak to your pharmacist or your healthcare provider to get a recommendation. Water-soluble lubricants (such as Astroglide or K-Y Jelly) can also be used on an as-needed basis. Non-water-soluble lubricants, such as Vaseline, are not recommended if you are using condoms for either contraception or for prevention of STIs because they can weaken latex and reduce the effectiveness of the condom. [5]
During the menopausal transition, the state of the vagina often changes. Vaginal dryness and pain are symptoms of vaginal atrophy (atrophic vaginitis) that occur as a result of lowered estrogen levels. The tissues in the vagina weaken, get thinner, dryer, and may get inflamed, causing pain, burning, or discharge.
Yes, it can be a contributing factor.
The lining of the outer urethra is estrogen-dependent. During the menopausal transition, this lining thins and may become weaker than the pressure in the bladder. It is this imbalance that leads to involuntary loss of urine.
Check out the science here
FALSE
Oh, please.
A national study of 5,045 older women [11] showed the following:
| Sexual activity among older US women | |||||
| Age (years) | 50-59 | 60-69 | 70-79 | 80+ | |
| Masturbated in previous year | 54% | 46% | 36% | 20% | |
| Had intercourse (penis-vagina) in previous year | 51% | 42% | 27% | 8% | |
| Received oral sex in previous year | 34% | 25% | 9% | 4% | |
FALSE
No, there are many safe and effective non- prescription medications that can be used to lubricate your vagina. A vagina is a muscle, and it needs exercise.
FALSE
Vaginal healthy aging can be had by using non-prescription lubes, HT with estrogen, and regular exercise with masturbation and intercourse.
References
[1] The North American Menopause Society. (n.d.). Changes in the Vagina and Vulva. Retrieved July 11, 2021, from https://www.menopause.org/for-women/sexual-health-menopause-online/changes-at-midlife/changes-in-the-vagina-and-vulva
[2] https://health.clevelandclinic.org/vaginal-discharge-mean/
[3] https://www.mayoclinic.org/symptoms/vaginal-odor
[4] https://my.clevelandclinic.org/health/symptoms/21027-vaginal-dryness
[6] Angelou K, Grigoriadis T, Diakosavvas M, Zacharakis D, Athanasiou S. The Genitourinary Syndrome of Menopause: An Overview of the Recent Data. Cureus. 2020 Apr 8;12(4):e7586. doi: 10.7759/cureus.7586. PMID: 32399320; PMCID: PMC7212735.
[7] Krause, M., Wheeler, T. L., 2nd, Richter, H. E., & Snyder, T. E. (2010). Systemic effects of vaginally administered estrogen therapy: a review. Female Pelvic Medicine & Reconstructive Surgery, 16(3), 188–195. https://doi.org/10.1097/SPV.0b013e3181d7e86e
[8] https://www.medicalnewstoday.com/articles/326977
[9] https://www.mayoclinic.org/diseases-conditions/vaginal-atrophy
[10] https://health.clevelandclinic.org/vaginal-steaming/
[11] Dumoulin, C., Cacciari, L. P., & Hay-Smith, E. (2018). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. The Cochrane database of systematic reviews, 10(10), CD005654. https://doi.org/10.1002/14651858.CD005654.pub4
Not AI generated.
Original content, last updated August 1, 2024.
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