You’ve endured the hot flashes and the night sweats and it’s been a year since your last period. You’re officially in menopause — and no more periods is definitely a reward for enduring the lead-up. The problem? Intimacy has started to feel uncomfortable, painful or just “off.” You were prepared for the hot flashes, mood swings and vaginal dryness, but this feels like your vagina is smaller after menopause. Is this even possible?
Yes, says Barbara DePree, MD, a gynecologist, certified menopause practitioner and director of Women’s Midlife Services at Michigan’s Holland Hospital. “It’s actually quite common,” she says, explaining that the loss of estrogen during the menopausal transition can cause the length, width and opening of the vaginal canal to shrink. “Lack of estrogen also causes vaginal tissue to become less flexible, which can contribute to a feeling of shrinkage.“
Doctors used to refer to a shrinking vagina at menopause, along with dryness and thinning of vaginal tissue, as a symptom of vaginal atrophy, says Lauren Streicher, MD, clinical professor of obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine. But doctors now consider atrophy and other vaginal symptoms as part of a phenomenon termed genitourinary syndrome of menopause (GSM). GSM encompasses the variety of physical changes that can happen in the vagina, on the vulva and in the urinary tract. (More on these changes later.) “The medical term acknowledges that there are many changes attributed to the drop in estrogen, and they’re not all vaginal.”
Why does declining estrogen play such a significant role in the health of everything “down there”? “This is the area of the body that has the greatest concentration of estrogen receptors, so the near-absence of estrogen in menopause plays a huge role here,” says Dr. DePree. In fact, she adds, it shouldn’t be surprising that the majority of postmenopausal women will develop some form of GSM over time.
Read on for more symptoms of GSM, plus strategies to overcome the painful sex caused by a shortened vagina.
More symptoms of genitourinary syndrome of menopause
Skin and tissue changes
Externally, the vulval tissue can become thin and dry, while the labia — particularly the labia minora, the two folds of skin that surround the vaginal opening — can become shorter and thinner and start to disappear, Dr. Streicher says. “The tissue surrounding the vagina often becomes pale, sometimes almost white; and if things get really dry, you may see angry-looking red patches.” Itching, burning and irritation of the vulva can also occur.
Internal symptoms include a loss of rugae, accordion-like folds of tissue in the vaginal walls that allow it to expand and contract during intercourse and childbirth. As these rugae disappear, the vaginal canal becomes less elastic, with walls that are thinner and more prone to tearing and irritation. “Those tissues just don’t stretch, and they’re so thin that if they are stretched, they can bleed,” says Dr. Streicher, host of Dr. Streicher’s Inside Information: Menopause, Midlife and More Podcast.
Increased risk of infections
Changing hormone levels can also cause a change in vaginal pH. A healthy vagina has a lower, or slightly acidic, pH of around 3.5 to 4 or 5, Dr. Streicher says. “But a menopausal vagina has a higher pH, which can wipe out the good bacteria that keep it healthy.” This can result in bacterial vaginosis and yeast infections.
A drop in estrogen can also cause thinning of the lining in the urethra and bladder, and the tissue damage that can result can lead to urinary tract infections (UTIs). “These more thin and dry tissues are less resilient at warding off bacteria from making their way on the outer skin, up the urethra and into the bladder, resulting in infection,” says Dr. DePree, founder of MiddlesexMD.com, an educational resource for women’s sexual health in perimenopause and beyond.
Estrogen loss combined combined with an age-related weakening of the pelvic floor significantly increases the risk of incontinence, Dr. DePree says. Click through for 4 natural treatments for incontinence.
Fortunately, not all women experience all of these symptoms. But most experience at least one, Dr. Streicher says. “Plus, they don’t always occur at the onset of menopause, but can develop years later, so a lot of women have no idea that having to get up at night to go to the bathroom or having that constant, gotta-go feeling can be a result of menopause.”
How to make the most of what you’ve got
A shrinking vagina, along with the dryness and other symptoms above, puts many women into “avoidance mode” when it comes to intimacy, says Dr. Streicher. “There are a lot of downstream consequences to painful sex,” she says. “Loss of libido, difficulty having an orgasm and a loss of intimacy that can sabotage relationships.”
Making matters worse? “So many women are told by their doctors that this is a normal part of aging,” Dr. Streicher says. But there’s good news: “These are all reversible changes. Unlike some issues where you have a window of opportunity to reverse them, you can reverse all of these changes at any point.” Read on for the simple MD-recommended strategies to outsmart estrogen loss.
“People can start with a lubricant and for some, they may not need anything more,” Dr. Streicher says, adding that the job of a lubricant is not to heal or repair tissue, but to decrease friction that causes pain and damage. And while a water-based product seems like a logical choice, she says, they don’t last long, and with continued use, many actually damage and dry out vaginal tissue. The reason, she explains, has to do with a very scientific term (osmolality) that refers to the amount of dissolved particles in a liquid. Most water-based lubes, she says, have a very high osmolality, which triggers vaginal cells to actually push water out, making the vagina even dryer over the long-term.
As Dr. Streicher writes in her book, Slip Sliding Away: Turning Back the Clock on Your Vagina: “Lubricants with high osmolality not only dry out tissue (the opposite of what you are trying to accomplish!) but also increase the chance of irritation and infection because the tissue becomes damaged. Hence, the irritation, burning, and itching that many women experience with regular use of many popular water-based lubricants.” The average vagina has an osmolality of around 300 mOmol/kg, she says, adding that whatever lubricant you’re using should ideally be as close as possible to that number.
“It’s shocking how many of the most popular lubricants have a sky-high osmolality,” says Dr. Streicher. But many women prefer water-based products. If you’re one of them, consider these products, which fit Dr. Streicher’s osmolality guidelines: Pulse H2Oh!, which has 300 mOmol/kg (Buy on LoveMyPulse.com, $30 for 36 uses) and Good Clean Love, which has 240 mOmol/kg (Buy on Amazon, $19.99 for a 2-pack).
Dr. Streicher prefers silicone lubricants, which are a little pricier, but they have no osmolality or pH issues that can harm vaginal tissue. They’re also the slipperiest, she says, adding that a little goes a long way. The downsides: Silicone lubricants can stain sheets and damage sex toys made with silicone (a problem that’s avoided by washing with soap and water after use). Two brands she likes: Replens Silky Smooth Silicone-Based Lubricant (Buy on Amazon, $14.96 for 2.7 oz) and SLIQUID Organics Silk (Buy on Amazon, $13.01 for 4.2 oz.)
Localized vaginal estrogens, which are safe for use for everyone, even women with a history of breast cancer, are another good option, says Dr. DePree. These prescription remedies can be administered via a cream, pill or ring. All are inserted into the vagina so the hormones go directly to the cells that need them without entering the bloodstream.
Vaginal moisturizers help increase moisture of vaginal tissues to heal and prevent tearing and damage. Dr. DePree advises moisturizers that contain hyaluronic acid, like Revaree (Buy at HelloBonafide for $62). Hyaluronic acid helps cells absorb moisture and has been shown to work as effectively as vaginal estrogen to prevent dryness and heal vaginal tissue. In fact, one study found that after a month of regular use, 84% of postmenopausal women reported relief of vaginal dryness and 57% saw a reduction in pain during sex. (Click through to our sister publication to discover more of the best natural remedies for vaginal dryness.)
Dr. Depree recommends vaginal dilators, which can be used in the comfort of your own home. This therapy involves inserting dilators that gradually increase in size into the vagina. A study in the journal Medicine found that 61% of women who used dilators got relief from vaginal shrinkage. Your doctor can prescribe dilators and explain how to use them, or you can buy them online. One to try: VuVa Smooth Dilator Set (Buy at VuVaTech, $48).
A healing supplement
One natural option that Dr. DePree suggests to her patients for vaginal dryness is to take 3,000 mg. of sea buckthorn oil capsules twice daily (one to try: Emerald Labs Sea Buckthorn, Buy on Amazon, $17.06 for 60 capsules). A small Finnish study published in the journal Maturitas found that compounds in the oil help vaginal tissue and lining retain moisture, and 60% of postmenopausal subjects reported beneficial effects, like strengthening vaginal tissue by 50% so it’s less susceptible to injury. What’s more, she says, there are non-estrogen prescription options, like Intrarosa and Osphena, that you can talk to your doctor about.
Lastly, using any of these strategies to ensure sex is comfortable — and making intimacy a priority — can also help reduce symptoms of GSM. “Regular intercourse stimulates blood flow, keeps vaginal muscles toned and helps maintain the length and stretchiness of your vagina.”
Click through to learn about more unusual symptoms of menopause:
This content is not a substitute for professional medical advice or diagnosis. Always consult your physician before pursuing any treatment plan.
A version of this article originally appeared in our print magazine, First For Women.