There’s a lot going on as we age, and not all of it is welcome. “A lot of women are blindsided by the changes that occur from menopause,” says Lauren Streicher, MD, a clinical professor of obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine in Chicago.
During menopause, women experience a drop in estrogen levels and physical changes to the vagina, vulva, and vaginal opening, which can cause symptoms like dryness and urinary tract infections. These changes, which used to be called vaginal atrophy, are now known as genitourinary syndrome of menopause (GSM), a condition that affects more than half of postmenopausal women, according to a research review.
The good news is that these changes can be treated — and reversed, says Dr. Streicher. Here’s what’s up down there.
1. Sex Can Be Uncomfortable — or Even Painful
Premenopause, the vagina has a thick wall that’s comprised of rugal folds, which are “accordion-like wrinkles that allow the vagina to expand to accommodate a baby or penis,” says Streicher. During menopause, she says, many women experience a thinning-out of that layer; what’s more, those rugal folds flatten, preventing the vagina from expanding.
The result of these changes: Penetration may be painful, even if you are aroused, says Streicher.
If intercourse is particularly painful — think “stabbing” or “fiery” pain — there may be a problem near the opening of your vagina. For example, doctors will sometimes see inflamed red patches in this area, says Streicher. “If a doctor touches a [cotton swab] here, people will say it’s painful,” she says.
Aside from intercourse, you may feel irritation or vaginal burning in general.
Over-the-counter vaginal lubricants or moisturizers can help improve comfort during intercourse or alleviate dryness, research has shown. “If you’re feeling dry, there’s no reason not to try one and see what it can do for you,” says Mary Jane Minkin, MD, a clinical professor of obstetrics, gynecology, and reproductive sciences at the Yale School of Medicine in New Haven, Connecticut.
If those options don’t work, you may want to talk to your doctor about whether you should take vaginal estrogen.
2. It Can Also Burn When You Pee
Feeling the burn? You aren’t the only one. The tissues that line the vagina and urethra are similar, in that they both have estrogen receptors, says Dr. Minkin. When estrogen levels decrease, these tissues begin to dry up, which gives “bad” bacteria a chance to populate. “You have this perfect storm for infection in the bladder and urethra,” she says. Drinking a lot of fluids and urinating regularly are both good habits to practice. Cranberry supplements can also help prevent bacteria from sticking to the wall of the bladder, says Minkin.
3. The Vulva Looks … Different
Menopause triggers changes to more than just the vagina; it can also alter the look of the vulva. “We see an actual thinning and flattening out of the labia minora,” says Streicher. “Over time, some women completely lose their labia minora.”
Here’s why that’s important to know: It’s not always enough to treat the inside of your vagina; outside problems can make penetration impossible, she says. At your appointment, a doctor should evaluate both areas.
4. The Vagina’s Microbiome May Shift
It’s not unusual for the vaginal pH to change with menopause. A normal, healthy vaginal pH is low, but as a woman develops GSM, that pH increases, says Streicher. A rise in pH alone won’t cause symptoms, but this change can alter the vaginal microbiome (a network of bacteria), leading to an increased risk of vaginal infections, says Streicher. Treatment with vaginal estrogen to manage other menopause-related symptoms can help decrease your pH levels and improve “good” vaginal bacteria, although estrogen treatment is not typically used solely to address pH issues. Talk to your doctor about your options.
5. You May Leak a Bit When You Cough
If that “gotta go” feeling hits so strong that you struggle to make it to the bathroom, your pelvic floor may be weak. “A lot of the urinary symptoms of incontinence [are] from the pelvic floor,” says Streicher. A physical therapist who specializes in pelvic floor exercises can be helpful, she says.