“What does it look like?”, I ask innocently.  The response always amazes me.  “I haven’t looked….should I… look….really?”.

If you haven’t seen your own vulva and vagina, today is the day!  Get out a mirror and have a good look.  It’s yours and you should know what it looks like, that way, when things go wrong, you will know what is happening to your own body. You will know when to seek help.

Once called Vulvar and Vaginal Atrophy (VVA) and recently updated to Genital Urinary Syndrome of Menopause (GSM), it doesn’t really matter what it’s called, hormonal changes in the genital area can impact your life.

When estrogen falls off during menopause or after a hysterectomy, the areas of the body that rely on estrogen start to wither and the highest concentration of estrogen receptors in the body is located in the genital area, encompassing the vulva, vagina, urethra and bladder.  So, as the vagina starts to lose it’s folds and becomes dryer and less elastic, symptoms can start to take hold including burning, irritation, overactive bladder and pain with intercourse.  Women who negotiate all the hot flashes, night sweats and insomnia and think they are in the clear – think again!  Vaginal symptoms don’t start for about 4-5 years AFTER menopause.  This is the main reason why many of my patients come to the office thinking they have a “yeast infection” that won’t go away.  We have become accustomed to calling every little twinge in the vagina a “yeast infection” when, usually, it is not and a proper assessment is needed.  The pain and irritation are so far removed from the last menstrual period that signaled menopause, it is difficult to relate the two.  To understand what is happening, picture the vagina like a lush, thick, bouncy lawn. The plush surface is protective and when the lawn is cut, the clippings lay atop the surface and act to fertilize the under layers so that it can quickly regrow.  The top layer of vaginal skin cells are like that too.  They slough off and provide food in the form of glycogen to the vagina and all the healthy organisms that live there.  The vaginal environment must remain in balance so that there is no overgrowth of yeast or bacteria and a certain acid-base level is required to keep this environment healthy.  This is called the pH and menopause leads to an increase in the pH, a lack of healthy vaginal “grass cuttings” and less fertile soil for the normal, necessary organisms to exist.  When the balance gets off kilter, overgrowth and infections can result.  Sex acts to rub against the skin in the vagina and if there are not enough layers to protect itself, the result is pain, bleeding, burning and irritation.

While it is very important to have your healthcare provider rule out other causes of the discomfort, you are not alone if you are diagnosed with vulvar and vaginal atrophy (or genital urinary syndrome of menopause).  Twenty-five to fifty percent of women will experience these symptoms and, without treatment, many will get worse over time.

But don’t despair, vagina rescue is available in many shapes and sizes.  As the problem is related to a lack of estrogen, the most effective treatment options include this hormone.  Vaginal options, also called “topical” because they are absorbed through the skin, include vaginal creams, vaginal tablets, vaginal rings and recently, an oral medication that specifically directs estrogen to the vaginal area.  While conventional hormone replacement therapy (HRT) will help, if the problem is between the legs, the treatment should be focused there too.  When hormones are focused on the genital area, the risks and side effects are much lower and generally it is very safe to use vaginal estrogen.  For women who cannot use hormones for one reason or another, there are over the counter vaginal moisturizers that may help.  

The best treatment is having regular sex because the friction inside the vagina will lead to a thickening of the skin and, ultimately, a healthier, more youthful vagina.  But be sure to use a good personal lubricant and apply it copiously and often.  Having pain during sex will often create a protective reflex in the pelvic floor muscles, leading to tightening, spasm and a constellation of other problems so be sure to stop or slow down if there is any pain.  It is important that you don’t just grit your teeth and bare it when it comes to pain with your partner.  

Interestingly, men are much more likely to avoid intimacy when they know their partners have pain than even the women themselves.  Men are equally likely to have decreased libido, feelings of inadequacy and concerns about pleasing their partners when there is painful intercourse so this is, very much, a marital issue, not just a female problem (Simon et. Al, Menopause 2014, 21(2): 137-142).

Sadly, 80% of conversations about sexual pain are not initiated by the doctor but, instead, by you, the patient so don’t be afraid to ask the tough questions. Over 90% of sexual problems are discussed during a healthcare visit for a completely unrelated medical reason and only 6% of patients have actually booked to talk about sex when they bring it up. While providers definitely need to improve on these statistics (Shifren JL et. Al, J of Women’s Health, 2009, 4: 466), women need to be proactive to get their concerns addressed.  In the current healthcare climate providers have less time, so it would be best to ask for a separate visit in order to properly review your sexual questions. If you don’t feel you are getting the answers you need or your doctor is avoiding your questions, ask for a referral to a sexual health specialist.  You and your partner will feel better when you get back to a pleasurable, comfortable and satisfying sex life.