Vaginal Dryness in Menopause

Vaginal dryness after menopause is common and usually needs treatment. Low estrogen thins the tissue of the vagina, vulva, urethra and bladder. This can cause dryness, burning, painful sex, urgency and repeated urinary infections, a cluster doctors call genitourinary syndrome of menopause. Moisturisers and lubricants ease symptoms. Low-dose vaginal estrogen treats the tissue change and often improves symptoms within a few weeks. It is safe for most women.

Why does vaginal dryness happen after menopause?

Estrogen keeps the vaginal lining thick, elastic, well supplied with blood and acidic. As estrogen falls, the lining thins to a few cell layers, loses its folds and stretch, produces less fluid, and its pH rises, which changes the bacteria living there. Blood flow and the nerve response that produce arousal and lubrication slow down. The urethra and bladder base, built from the same estrogen-sensitive tissue, thin too.

Unlike hot flashes, which are a brain response that eventually settles, this is a tissue change that continues as long as estrogen stays low. Women often notice it two to five years after their last period, later than the other symptoms, and don’t connect it to menopause.

Symptoms beyond dryness

You may have more than one of these:

• Dryness, itching or burning of the vagina or vulva, sometimes constant
• Pain, rawness or bleeding with sex, and less sensation
• Discomfort with tight clothing, cycling, or sitting
• Urgency, going more often, or leaking
• Burning with urination without an infection
• Recurrent urinary tract infections (see bladder symptoms in menopause)
• Thin, watery or yellowish discharge, or a change in odour
• Less lubrication and slower arousal, and the low libido that can follow painful sex

Does it go away?

No. This symptom does not usually resolve with time. Left alone, it tends to progress. Treatment can restore the tissue at 55, 65 or 80, no matter how long you’ve had it.

What helps: moisturisers and lubricants

These relieve symptoms without treating the cause, and they’re worth using alongside treatment.

Vaginal moisturisers are used regularly, two or three times a week, not just for sex, and help the tissue hold water. Look for an unscented product labelled as a moisturiser; hyaluronic-acid-based ones have modest trial support.

Lubricants are for sex. Silicone-based ones last longest and don’t irritate. Water-based ones are fine if they’re free of glycerin, warming or tingling agents, flavour and fragrance, which can irritate thin tissue. Avoid petroleum products; coconut and other plant oils can damage latex condoms.

Avoid douching, scented soaps and wipes, bubble bath and “feminine hygiene” products. Use plain water to wash. Cotton underwear and less tight synthetic clothing may help.

Vaginal estrogen: the first-line treatment

Low-dose estrogen applied in the vagina rebuilds the lining, restores elasticity and moisture, lowers pH back to normal, and reduces urinary symptoms and recurrent infections. Guidelines recommend it first for these symptoms.

Forms. Options include a cream used with an applicator, a small tablet or insert placed with a finger or applicator, or a soft ring that sits in the vagina for three months. They all start with daily use for about two weeks, then drop to twice a week. Improvement begins within two to four weeks and continues for a few months.

Safety. The doses are tiny, and the hormone acts on the tissue it touches; blood levels stay in the postmenopausal range. Because of that, it doesn’t carry the risks associated with systemic hormone therapy, and a progestogen isn’t needed to protect the uterus. It can be used indefinitely; symptoms return if it’s stopped. Women with a history of breast cancer should have the conversation with their oncologist, but many can use it, particularly those not on aromatase inhibitors, and the major societies regard it as reasonable in that situation. The package insert carries the same warnings as systemic estrogen, which experts have long argued are not relevant at these doses; your clinician can explain the gap.

Other prescriptions

• Vaginal DHEA (prasterone), a nightly insert that the tissue converts to estrogen and testosterone locally; FDA-approved for painful sex.
• Ospemifene, a daily tablet that acts like estrogen on vaginal tissue; FDA-approved for painful sex and dryness, for women who prefer not to use a vaginal product. It can cause hot flashes.
• Vaginal testosterone is used by some clinicians but has less evidence.

Does HRT fix vaginal dryness?

Often, but not reliably on its own. Systemic hormone therapy taken for hot flashes improves vaginal symptoms in many women, yet a sizeable minority still need a local treatment as well, and the standard advice is to add vaginal estrogen rather than raise the systemic dose. If you’re on HRT and still dry or still getting infections, say so; it isn’t a sign the HRT is failing.

Lasers and “vaginal rejuvenation”

Vaginal laser and radiofrequency treatments are marketed heavily for dryness and tightness. The FDA issued a safety communication in 2018 warning that these devices have not been shown safe or effective for menopausal symptoms, and the better trials since have not shown an advantage over vaginal estrogen or even over sham treatment. They’re expensive and not recommended outside research.

When to see a doctor

Dryness itself warrants a visit because the treatment is a prescription. See someone promptly, rather than at the next routine visit, for:

• Any bleeding after menopause, including after sex. It’s usually the thin tissue, and it always needs checking.
• Sores, lumps, or a patch of skin that is white, thickened or persistently itchy
• Discharge with a strong smell, or pelvic pain
• Urinary symptoms with fever or back pain

Getting help

Vaginal dryness is quick to treat and doesn’t require an examination to start. A video visit with a Golden Leaf Health clinician licensed in your state can prescribe vaginal estrogen or an alternative, with follow-up to check it’s working. Book a first visit.

Sources: The Menopause Society; ACOG, Experiencing vaginal dryness? Here’s what you need to know; Mayo Clinic, Vaginal atrophy; FDA, safety communication on energy-based devices for vaginal rejuvenation; National Institute on Aging, Sex and menopause.