Treating the Incredible Shrinking Vagina

Treating the Incredible Shrinking Vagina


So, vaginal atrophy. What’s that about? I (very tentatively) asked my general practitioner about how the whole “vagina after menopause” thing works and she was basically “yeah, that’s right, it will atrophy.” So what can be done about it, if anything? Frankly, I’m a bit sad.

— Shrinking Violet

[Have a question about women’s health? Ask Dr. Gunter yourself.]

There are changes that happen to the vagina and vulva with menopause. We used to call this vaginal atrophy, as the tissue becomes thinner and can even shrink. However, that terminology — while technically medically accurate for some menopause-related changes — sounds dismissive and neglects the fact that these changes affect more than the vagina. We now refer to these changes as genitourinary syndrome of menopause or G.S.M. The vulvar and vaginal symptoms of G.S.M. are distressing for many women. Fortunately, they can almost always be treated.

G.S.M. is primarily caused by dropping levels of estrogen during menopause. As a result, the skin of the vulva and the vagina become thinner with a loss of elasticity. The labia minora can also reduce in size.

Common symptoms of G.S.M. include vaginal or vulvar dryness. Other symptoms can occur during sex, including loss of lubrication, an uncomfortable sandpaper-like sensation, pain, difficulties achieving orgasm and even tearing of the vagina or vulva. There is also an increased risk of urinary tract infections.

As estrogen is crucial to maintaining the bacterial colonies of the vagina, there can also be a change in the type of bacteria, which can lead some women to notice a change in their typical smell.

As many as 15 percent of women report symptoms of G.S.M. during perimenopause, which is the time around menopause when estrogen production is starting to drop. Some women can have bothersome symptoms for years before their menstrual cycle stops and others have no symptoms at all. And there is every variation in between.

Approximately 50 percent of women report symptoms of G.S.M. by three years after menopause. (Menopause has occurred when you have gone one full year without a menstrual period.)

Whether you are in perimenopause or your last period was five years ago, there are many excellent therapies for G.S.M., so suffering with symptoms isn’t necessary. Your treatment choices will depend on your symptoms (what I like to call your “bother factor”), personal preferences and your medical history.

Some general recommendations you can try:

  • If you have urinary incontinence, use incontinence pads, not menstrual pads. Menstrual pads are designed differently than incontinence pads and will keep the wetness of the urine against the skin, potentially contributing to vulvar irritation.

  • Try vaginal moisturizers for vaginal dryness. These are over-the-counter products that you use every two to three days. These products are less likely to be helpful, however, if you have more than one symptom.

Beyond these suggestions, pharmaceutical options may also be helpful. Vaginal estrogen, which is available as either estradiol or conjugated equine estrogens, are considered the gold standard to replace the estrogen your body is no longer making after menopause. They come in a wide range of formulations including creams, a vaginal ring, vaginal tablets and gel caps. Vaginal estrogen is very safe and not associated with breast cancer or stroke when used as recommended.

A newer pharmaceutical option is intravaginal DHEA (dehydroepiandrosterone), a hormone that is converted to estradiol and testosterone in the vaginal tissues. DHEA is newer and has not been as well studied as the two types of vaginal estrogen, so it is something to consider if they have been tried first and have not been effective. Possible downsides to DHEA: It is a daily application and some find it messy.

There may be other medical explanations for the symptoms you are dealing with, so if G.S.M. is suspected, your doctor may suggest you try any medicine for at least six weeks to see if it helps. After that, if vaginal products have not alleviated the symptoms, a re-evaluation is indicated.

There is no reason to suffer with G.S.M. If your doctor is not responsive to your concerns, you can find a provider who knows more about G.S.M. via N.A.M.S.

Some health care providers and pharmacies advertise “bioidentical” hormones for use after menopause. This is a marketing term, not a medical term. “Bioidentical” has been used to describe hormones that are chemically identical to what the ovary makes or for hormones derived from a plant source. These products are often marketed as “more natural” or “safer” than pharmaceutical options, but they are not.

There are dosing and safety concerns with “bioidentical” hormones, and these formulations are not F.D.A. approved.

Dr. Jen Gunter, often called Twitter’s resident gynecologist, is teaming up with our editors to answer your questions about all things women’s health. From what’s normal for your anatomy to healthy sex and clearing up the truth behind strange wellness claims, Dr. Gunter, who also writes a column called The Cycle, promises to handle your questions with respect, forthrightness and honesty.



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