Estrogen plays an important role in the health of the vagina. During menopause when women’s ovaries stop producing estrogen, changes in the vaginal tissues can occur. This constellation of symptoms has suffered a naming crisis over the years - being called vaginal dryness, atrophic vaginitis, vulvovaginal atrophy, and now the latest term: “genitourinary syndrome of menopause” or “GSM.” GSM refers to symptoms that occur due to the loss of estrogen such as frequent bladder infections, pain or urgency with urination, pain with intercourse, lack of lubrication during intercourse and vaginal burning, irritation and itching. In one study, fifty percent of postmenopausal women report symptoms of GSM, but only 6-7 percent of women receive treatment for these bothersome concerns. The changes that occur in the vagina and surrounding tissues happen slowly, so that women often don’t notice they’re occurring until one day they note pain with sexual intimacy. It’s important to note that symptoms of GSM do not improve over time; they tend to worsen the longer the vagina is without estrogen. 1
While GSM can cause daily concerns with itching, discomfort and frequent infections, what we’re focusing on in this piece is the discomfort that can occur when the vaginal tissues become fragile due to the loss of estrogen. Anytime a woman experiences pain with intercourse, it lessens her interest in pursuing intimacy the next time. Sometimes the pain becomes so severe that the vaginal muscles will spasm - causing even more pain. The muscles of the vagina have a long memory, and if they start to spasm with intercourse, the spasms can occur at the start of every intimate moment.
When women have pain with intercourse it usually starts in the outer third of the vagina. The good news is that this area is easily reached with topical (local) preparations.
What are some ways we can keep our vaginas healthy? The great news is that researchers and scientists realize sexual function is important to women, so lots of research dollars are being spent to find great solutions.
Vaginal estrogen - Estrogen improves the health of the vagina by plumping up the lining and improving the pH and microbiome. What’s great now is that women who are appropriate for low dose topical estrogen therapy now have many mechanisms for applying it including a vaginal tablet inserted with an applicator, vaginal cream inserted with an applicator, vaginal capsule, and vaginal ring (Estring). The safety of vaginal estrogen has been studied extensively. A recent analysis of 38 studies provides tremendous reassurance about the safety and efficacy of this effective treatment.2 A review of 18 years of data from The Nurses Health Study also showed no increased risk of cardiovascular disease or cancer with the use of vaginal estrogen. 1 Dr. Tara Allmen, in her book Menopause Confidential, compares the vagina to Vegas: similar to the phrase “What happens in Vegas stays in Vegas,” what goes in the vagina stays in the vagina.
Vaginal DHEA (Prasterone) - This is a hormone which is a precursor to estrogen and testosterone. Studies show that when it is inserted in the vagina, over time, vaginal pain decreases.
Activity - The old adage, “use it or lose it” holds true in this area of the body just like it does in others. Regular sexual practice - whether with a partner, solo, or a device - helps keep the tissues healthy by bringing blood flow to the area. Pelvic floor physical therapy with a trained therapist can also help improve blood flow.
Non-hormonal options - Women have access to multiple OTC vaginal lubricants (which are used during intimate moments) and vaginal moisturizers (which are used daily). Some popular lubricants are Slippery Stuff and Aloe Cadabra. I heard a lecturer remind a group of women that to keep their youthful complexion they’ve certainly been applying moisturizers to their faces since their teenage years; similarly, we can now apply moisturizers to our vaginas to maintain their youthful properties. Examples of vaginal moisturizers include Replens, Revaree, olive oil, and coconut oil.
Ospemifene - This is an oral pill that selectively talks to the estrogen receptors in the vagina and the endometrium and has been shown to decrease pain with sexual intercourse and improve the symptoms of vaginal dryness.
Vaginal laser treatments - Laser treatments are not FDA-approved to treat vaginal health, but they have been used off-label successfully in many women.
Important points to keep in mind:
Once a woman has gone through menopause (a year without a period or removal of the ovaries), she should report any vaginal bleeding to her health care provider.
All estrogen-containing products, no matter what kind or what dose, are required by the FDA to have a boxed warning telling about the harms that occurred in the Women’s Health Initiative. Please see our blog post about this or discuss with one of our providers.
1. Bhupathiraju SN, Grodstein F, Stampfer MJ, et al. Vaginal estrogen use and chronic disease risk in the Nurses’ Health Study. Menopause 2018;26(6):603–10.
2. Constantine GD, Graham S, Lapane K, et al. Endometrial safety of low-dose vaginal estrogens in menopausal women: a systematic evidence review. Menopause 2019;26(7):800–7.