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Vaginal & Urinary Changes

What do we mean by vaginal and urinary changes?

Changes to the vagina, vulva, and urinary tract, which are related to aging and a decline in estrogen as we approach our final menstrual period.
These changes are part of a larger bucket of symptoms called the Genitourinary Syndrome of Menopause (GSM). All of these tissues are sensitive to changes in estrogen. When estrogen decreases tissues become drier, less flexible, and thinner.

The previously used term was vulvovaginal atrophy (VVA).

GSM RELATED SYMPTOMS
  • Vaginal dryness
  • Vaginal itchiness
  • Painful sex
  • Burning
  • Painful urination (dysuria)
  • Urinary frequency or urgency
  • Trouble holding urine
  • UTIs
  • Discomfort during pelvic exams – especially speculum exams

3 things to know about vaginal & urinary changes

  • Vaginal changes usually begin with irritation, itching, dryness and pain with sex.

  • Too many women and their healthcare providers are uncomfortable talking about vulvovaginal changes so this important topic doesn’t get discussed.

  • Vulvar and vaginal changes don’t get better over time. If you are experiencing either, talk to your healthcare provider. These changes are treatable.

The menopausal transition has been a difficult one — one that I am still challenged by — particularly with respect to vaginal changes.  When you were once very sexual and enjoyed intercourse and suddenly that changes, it’s quite a loss.  It’s very hard now to associate pleasure with intercourse, as it has become painful despite the lubricants.  Be creative and buy a vibrator!
WLB Community Member

WLB 2020 SURVEY RESULTS

These data represent the % of respondents reporting each symptom on the Women Living Better Survey. LRS stands for the late reproductive stage and MT for the Menopause Transition. These are two stages on the path to menopause (the final menstrual period).

Vaginal Changes

Pain with vaginal sex

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

Less vaginal lubrication

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

Vaginal dryness

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

Vaginal itchiness

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

Urinary Changes

*Issues with leakage can come from both a decline in estrogen (vagina and bladder have estrogen receptors) and pelvic floor dysfunction.

Urinary leakage with sneezing or cough

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

Urinary leakage at other times

(other than sneezing or cough)
Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

Increased frequency of urinating

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

Urinary urgency

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%
Genitourinary syndrome of menopause affects approximately 27% to 84% of postmenopausal women and can significantly impair health, sexual function, and quality of life.

The North American Menopause Society (NAMS) 2020 Position Statement

This seems like a very wide range and might have to do with the various ways questions about GSM are asked in research.

Hormones & vulvar and vaginal changes

Vulvar and vaginal changes tend to begin in the later stages of perimenopause, closer to the final menstrual period, when estrogen levels are declining, although for some women these symptoms do not appear until a year or more after the final menstrual period.

Estrogen makes vaginal tissues moist and flexible and increases lubrication during arousal. Without this lubrication, penetration can become painful. As we experience lower levels of estrogen over time, vaginal symptoms can get worse so talk to your healthcare provider if you experience these symptoms.

The thinner, more fragile vulvovaginal tissue in combination with lower immunity associated with aging, can lead to more urinary tract infections (UTIs).

Remedies to help with vulvar and vaginal changes

OVER THE COUNTER

Moisturizers can relieve irritation

Moisturizers are absorbed into vaginal tissue and add moisture that can help relieve everyday itchiness and irritation that many women experience. You use these 2-3 times a week to maintain moisture. Hyaluronic acid is the base for most moisturizers.

Lubricants to minimize friction during sex

Lubricants are only used to minimize friction during sex. They are not absorbed into the tissue. They come in liquid or gel and are applied to the vagina or penis. These should be silicone or water-based. Only water-based or silicone lubricants should be used with condoms.
BY PRESCRIPTION

Vaginal Estradiol can re-invigorate vaginal tissue

Vaginal Estradiol is used to re-invigorate vaginal tissue and prevent further structural changes. This can be delivered by a ring, tablet, or ovule capsule inserted into the vagina or cream applied inside the vagina and on the labia. Even though these products are inserted into the vagina, they are considered topical applications of estrogen to treat the local cells and act locally on tissues. There is some but very little systemic exposure. Many oncologists support the use of vaginal estrogen in breast cancer survivors. These products require a prescription from your healthcare provider. Brand names: Vagifem®, Estring®, Estrace®

Selective Estrogen Receptor Modulators can treat painful sex and discomfort

Selective Estrogen Receptor Modulators (SERMS) are used to treat painful sex and discomfort associated with vaginal dryness. It comes in oral pill form and has systemic effects. This NIH site lists reasons why some people should not take a SERM. Brand name: Osphena®

DHEA is a non-estrogen treatment for GSM and painful sex

DHEA is a vaginal, non-estrogen treatment for painful sex, which is used nightly. It contains DHEA-a hormone and is paired with palm and coconut oil. Brand name: Intrarosa®. 
IN-OFFICE TREATMENT

Laser or radiofrequency treatments claim to rehabilitate vagina tissue

Laser or radiofrequency treatments claim to rehabilitate vagina tissue. Research on these is mixed. They are expensive and not covered by insurance.

A recent 2022 systematic review concluded: that CO2-Lasers are a safe therapeutic option for the management of GSM symptoms in postmenopausal women; but noted that “the quality of the body of evidence is “very low” or “low”.”

ADDITIONAL RESOURCES
I always tell patients that the package insert for vaginal estrogen (topical) is the same as for oral estrogen and it can be scary to read the risks/warnings. However, research documents that applying estrogen vaginally results in lower systemic levels, not the same as when you take it orally. I also warn them that insurance coverage for vaginal estrogen varies widely and it can be very expensive.

Dr. Marcie Richardson
ObGyn
Founder, Menopause Clinic, Atrius Health, Boston

REFERENCES

  1. Vale F, Rezende C, Raciclan A, Bretas T, Geber S. Efficacy and safety of a non-hormonal intravaginal moisturizer for the treatment of vaginal dryness in postmenopausal women with sexual dysfunction. Eur J Obstet Gynecol Reprod Biol. 2019 Mar;234:92-95. doi: 10.1016/j.ejogrb.2018.12.040. Epub 2019 Jan 11.
  2. Portman DJ, Gass ML; Vulvovaginal Atrophy Terminology Consensus Conference Panel, Menopause. 2014 Oct;21(10):1063-8)
  3. Hussain I, Talaulikar VS. A systematic review of randomized clinical trials – The safety of vaginal hormones and selective estrogen receptor modulators for the treatment of genitourinary menopausal symptoms in breast cancer survivors. Post Reprod Health. 2023 Oct 16:20533691231208473. doi: 10.1177/20533691231208473. Epub ahead of print. PMID: 37840298.
  4. Filippini M, Porcari I, Ruffolo AF, Casiraghi A, Farinelli M, Uccella S, Franchi M, Candiani M, Salvatore S. CO2-Laser therapy and Genitourinary Syndrome of Menopause: A Systematic Review and Meta-Analysis. J Sex Med. 2022 Mar;19(3):452-470. doi: 10.1016/j.jsxm.2021.12.010. Epub 2022 Jan 29. PMID: 35101378.