Urogenital Atrophy

The discomforts in the vagina and vulva (external labia of the vagina) are common in women of all ages, but they increase with menopause. The decrease in estrogen during menopause is the main contributing factor in vaginal dryness, itching, burning, discomfort and pain during sexual intercourse or any other sexual activity. Vaginal atrophy is the medical term that describes these changes and when they combine with the bladder symptoms during menopause, it’s called genitourinary syndrome of menopause. The symptoms of vaginal atrophy can significantly affect the quality of life, sexual satisfaction and the relationship with your partner.

The vaginal symptoms associated with menopause can begin to cause early discomfort in the menopause transition or begin several years after with the decrease in the levels of estrogen. Contrary to the hot flushes, which in general improve with time, the vaginal symptoms usually worsen in time, due to the aging as well as the prolonged lack of estrogens.

Menopause and aging can affect the vagina in the following ways:

The vaginal tissue gets thinner, dryer and less elastic.
The vaginal secretions are less and lubrication decreases.
There’s an increase in vaginal infections (since the normal Ph of the vagina is increased)
There can be discomfort when urinating and an increase in urinary tract infections.
The fragile, dry and swollen vaginal tissue can tear apart and bleed.
Women with induced menopause due to cancer treatments can have additional damage in the vaginal tissue because of chemotherapy or pelvic radiation.
The aromatase inhibitors that many women with breast cancer take cause extremely low levels of estrogens, usually causing severe symptoms of vaginal dryness and a decrease in lubrication.
The vaginal changes commonly contribute to pain during sexual intercourse or vaginal exams.
Women with discomfort due to vaginal atrophy usually have sexual activities with less frequency, causing the vagina to be shorter, narrower and less elastic.
For some women, pain and vaginal narrowing and involuntary contractions of the vaginal muscles (vaginismus) can intensify to the point where sexual relations are no longer pleasurable or even possible.

Treatment options: even though the symptoms of dryness and vaginal atrophy may be unpleasant, the good news is there are effective treatment options. These include different types of estrogens, in low dosage, applied directly in the vagina, as well as non-hormonal treatments. You can combine non-hormonal and hormonal treatments for an optimum relief of the symptoms.

Exercises for the pelvic floor can strengthen the relaxed vaginal muscles and relax the ones that are tight.
Vaginal lubricants reduce discomfort during sexual activity when the vagina is dry due to a decrease in friction. Water based products are recommended, given that the oil content in some of them can cause vaginal irritation. There are many brands available over the counter that are very effective, such as K-Y jelly, Astroglide, K-Y Silk-E, Slippery Stuff and Just Like Me.
Vaginal moisturizers cover the vaginal wall and keep vaginal moisture. As with your face and hands, the vagina must be moisturized regularly; for example, many times a week before going to sleep. There are effective products like Replens and K-Y Liquibeads.
Regular sexual stimulation promotes the vaginal blood flow and secretions. Sexual stimulation with a partner, alone or with a device (such as a vibrator) can improve your vaginal health.

Vaginal therapy with estrogens

It’s a prescribed available treatment, which is effective and safe; consists on applying a low dosage of estrogen directly in the vagina to increase the thickness and elasticity of the vaginal tissues, reestablish vaginal secretions and relieve vaginal dryness and discomfort during sexual relations. Improvement usually happens in a few weeks, although total relief may take several months.
A short term treatment can be an option for women with a history of breast or uterine cancer, but only after carefully considering the risks and benefits with your physician.
There are products with a low dosage of estrogen, which are approved for vaginal application, such as vaginal creams (used 2 or 3 nights a week), estradiol vaginal tablets (used twice a week) and an estradiol vaginal ring (changed every 3 months). All these are highly effective. You can try different options and pick the one you prefer.
The standard dosage of estrogen therapy tested to treat hot flushes also treat vaginal dryness, although some women may benefit from an additional treatment with low dosage vaginal estrogens. If there are only vaginal symptoms, low estrogen dosages are recommended only applied in the vagina.