- Vaginal and vulval changes during menopause occur as the reduction in estrogen leads to thinning and loss of elasticity of vaginal and vulval tissues.
- Symptoms include burning, dryness, inflammation, itching, and pain in the vagina and vulva, patchy vulva skin, pelvic issues including prolapse, vaginal discharge, and vaginal tear.
- A diagnosis is made from a medical and sexual history review, physical examinations, and tests like vaginal pH testing, vulval skin biopsies, pap smear, and diagnostic imaging.
- Treatment options include hormone replacement therapy, medications, topical creams, moisturizers, and lubricants, medical devices, therapies, and dietary supplements.
- Management options include probiotics, avoiding irritants, regular physical exercise, pelvic floor, or Kegel exercises, and open communication about sexual health and symptoms.
What is it?
Menopause-related vaginal and vulval changes encompass a range of symptoms affecting a woman’s external genitalia, vagina, bladder, urethra, and pelvic region, primarily because of the decline in estrogen levels. This hormonal change leads to a condition known as genitourinary syndrome of menopause (GSM), which encompasses vulvovaginal atrophy (VVA).
Symptoms include burning, dryness, inflammation, itching, and pain in the vagina and vulva. These changes can also result in patchy skin on the vulva and various types of vaginal discharge. Menopause can contribute to pelvic issues, such as pelvic floor dysfunction and pelvic organ prolapse (POP), because of weakened pelvic muscles and tissues. Vaginal tears (non-obstetric vaginal lacerations) may also occur, often exacerbated by the thinning and drying of vaginal tissues.
Vaginal and vulval changes represent a significant shift in a woman’s reproductive health during menopause, affecting not only physical comfort but also potentially affecting sexual function and overall quality of life. Understanding and addressing these changes is crucial for maintaining health and well-being during the menopausal transition.
What causes it?
The primary cause of vaginal and vulval changes during menopause is the decline in estrogen levels. Estrogen is crucial for maintaining the health, elasticity, and lubrication of the vaginal and vulval tissues. As menopause progresses, the reduction in estrogen leads to thinning and loss of elasticity in these tissues, as well as a decrease in vaginal lubrication.
The bladder, vestibule of the vulva (containing the urethral and vaginal opening), vagina, and urethra are all affected because of their high levels of estrogen receptors. The reduction in estrogen can cause dryness, discomfort, and pain in these areas. Pelvic floor muscles become thinner and less flexible, leading to weakness and possible POP.
Other factors that may exacerbate vaginal and vulval changes include childbirth, medical interventions like chemotherapy or radiation, autoimmune disorders, and specific skin conditions. These changes can be uncomfortable and distressing; however, they can be managed effectively with appropriate treatment.
What are the symptoms?
Symptoms of vaginal and vulval changes can manifest in various forms, such as burning, dryness, inflammation, itchiness, or pain. These discomforts may occur separately or concurrently, and their intensity can vary from mild to severe. These changes can also result in patchy skin on the vulva and various types of vaginal discharge.
Additionally, menopause can contribute to pelvic issues, such as pelvic floor dysfunction and POP. Non-obstetric vaginal lacerations may also occur, often exacerbated by the thinning and drying of vaginal tissues.
Understanding these symptoms can aid in early detection and prompt treatment of underlying conditions.
Burning Vagina and Vulva
A burning sensation in the vagina, the internal muscular canal that connects your genitals to the uterus, can occur when urinating or during sexual intercourse. The burning sensation can begin suddenly or escalate over time. Besides GSM, reasons for vaginal burning include bacteria in the vagina (bacterial vaginosis (BV)), a yeast infection (vaginal candidiasis), a urinary tract infection (UTI), sexually transmitted infections (STIs), or contact allergies from substances such as spermicides, the fluid found in condoms, rubber, as found in diaphragms, and douches, device used to wash the vagina.
A burning sensation in the vulva, the external part of your genitalia, including the clitoris, labia majora, and minora (or outer and inner lips), urethral opening, and vaginal opening, can occur suddenly or escalate over time. The burning sensation may be felt over the entire vulva or in one location, such as the clitoris. Besides GSM, other reasons for vulvar burning may include contact dermatitis, red patchy vulva skin (Vulval Lichen Planus), white patchy vulva skin (Vulval Lichen Sclerosus) and a painful vulva (vulvodynia).
Other symptoms include vaginal discharge, itchiness, redness, and soreness of the vagina and vulva. Persistent burning or discomfort should be evaluated by a healthcare professional as they may be related to other conditions, such as infections, skin disorders, or cancer.
Dry Vagina and Vulva
Menopausal women commonly experience vaginal and vulval dryness as their estrogen levels decline. This reduction in estrogen leads to the lining of the vagina becoming drier and thinner, a condition known as GSM, previously and also known as vaginal atrophy or atrophic vaginitis. Alongside these changes, some women may develop vaginal stenosis, a narrowing, and shortening of the vaginal canal, which can further contribute to discomfort. Vaginal stenosis can also result from chemotherapy, radiation therapy, or surgery around the pelvic area.
In addition to dryness, symptoms of GSM may include itching, burning, spotting, and irritation in the vaginal and vulval areas. Women might also experience a sensation of pressure, reduced vaginal lubrication, or pain (dyspareunia) during sexual activity. Additionally, symptoms like frequent urination and urinary tract infections can occur.
Given these symptoms can resemble those of infections and dermatological conditions, consulting with a medical professional is advisable for accurate diagnosis and management.
Inflamed Vagina and Vulva
An inflamed or infected vagina (vaginitis) and vulva (vulvitis), or both (vulvovaginitis), typically manifests as redness, swelling, and soreness in the vaginal and vulval area, or both.
Women may experience a burning sensation, especially during urination or sexual intercourse.
Others experience a strong odor and vaginal discharge, which may differ in color, consistency, and odor from normal secretions. Some have spotting or light bleeding not linked to menstruation. Other women experience persistent itching, leading to discomfort and distress. The most common types are bacteria in the vagina (BV), yeast infections (vaginal candidiasis), and the sexually transmitted infection (STI) trichomoniasis, or trich, caused by a parasite.
Itchy Vagina and Vulva
An itchy vagina can be a symptom of vaginitis or vulvovaginitis if the inflammation or infection also involves the vulva. An itchy vulva (pruritus vulvae) can be a symptom of vulvitis or vulvar dermatitis. Vulvar dermatitis is a skin condition that causes an itchy, irritated, and inflamed vulva, often with patchy, scaly skin. Vulvar dermatitis includes atopic dermatitis (vulvar eczema) and contact dermatitis. Typically, dermatitis is triggered following an allergic reaction, irritated skin such as psoriasis, or inflammatory conditions.
The itchiness can be constant or intermittent, accompanied by redness, swelling, or a burning sensation. Other associated symptoms may include vaginal dryness, discharge, and discomfort during sexual intercourse. Where vulvar itchiness becomes chronic, it may be diagnosed as vulval lichen simplex. Vulval lichen simplex is a form of dermatitis in which excessive scratching or rubbing can lead to disturbed sleep and thick and leathery skin called lichenification.
While these symptoms can be a natural part of the menopausal transition, they can also indicate infections such as yeast infections (vaginal candidiasis), BV, or sexually transmitted infections (STIs). Therefore, consultation with a healthcare professional is recommended if itchiness is persistent or severe.
Painful Vulva (Vulvodynia)
Vulvodynia can present as a burning, stinging, rawness, or sharp stabbing and pain in the vulva. The pain may be constant or intermittent and can occur during or after physical activities like cycling, sexual intercourse (dyspareunia), or prolonged sitting. The severity of symptoms varies widely among women, and the pain may be localized to a specific area or involve the entire vulval region.
Other associated symptoms may include urinary urgency, painful menstruation, and discomfort while wearing tight clothing. Unlike other conditions that affect the vulva, vulvodynia rarely has visible signs of a skin condition like redness or a rash.
Patchy Vulva Skin
Patchy skin on the vulva, encompassing conditions like Vulval Lichen Planus and Vulval Lichen Sclerosus, is characterized by distinct skin changes and texture.
In Vulval Lichen Planus, women may notice red, patchy areas on the vulva, often accompanied by itching, burning, or soreness. This condition can also cause discomfort during sexual intercourse and may lead to the vulva’s skin becoming thinner and more fragile.
On the other hand, Vulval Lichen Sclerosus typically presents as pale, white, or silver, patchy skin on the vulva. This condition can cause severe itching and pain, and the skin may become thin and fragile, bruising, splitting, or tearing easily. Bruises may look like blood blisters.
Other conditions, such as contact dermatitis, vulvar psoriasis, vulvar eczema, fungal infections, bacterial infections, and vulvar intraepithelial neoplasia, a precancerous condition, can all involve various forms of patchy skin.
Pelvic Issues
Pelvic issues during menopause, including pelvic floor dysfunction and pelvic organ prolapse (POP), significantly affect a woman’s pelvic health. The decline in estrogen can weaken pelvic floor muscles, leading to symptoms like discomfort, sexual dysfunction, urinary incontinence, and difficulties with bowel control. A woman’s pelvic floor muscles have likely already weakened from childbirth through vaginal delivery, and some experience POP as a result.
Women may experience a sensation of heaviness, fullness, or pressure in the vagina, or a sensation of something coming down through the vagina, key signs of POP, where pelvic organs like the bladder, uterus, or rectum drop and press against the vaginal wall.
A painful pelvic region, often associated with pelvic floor dysfunction, can manifest as aching or sharp pain in the lower abdomen, back, or genital area. This pain can be exacerbated during physical activities, sexual intercourse, or while using the bathroom. The weakening of pelvic muscles and ligaments during menopause can also reduce support for pelvic organs, affecting bladder and bowel functions.
Vaginal Discharge
Vaginal discharge during menopause can vary, reflecting changes in estrogen levels. Normal discharge is typically clear or milky white, without odor, and its consistency and volume can fluctuate throughout the menstrual cycle. For instance, around ovulation, discharge may become thinner and more abundant. However, during menopause, as estrogen levels decrease, the amount of normal discharge often reduces.
Abnormal vaginal discharge, however, can signal an underlying issue. It may become heavier, thicker, or change in color, appearing grayish, greenish, yellowish, or even blood-tinged. A foul or fishy odor and symptoms like itching, burning, redness, or soreness often indicate an infection or inflammation, such as vaginitis. These changes can be because of various factors, including hormonal imbalances, infections, or certain medications.
Additionally, vaginal discharge may be caused by other conditions, such as Pyometra, which is a uterine infection. Understanding the nature of vaginal discharge during menopause is crucial, as it helps in distinguishing normal and abnormal changes and when to consult a healthcare professional.
Vaginal Tear
Vaginal tears (non-obstetric vaginal lacerations) are distinct from those occurring during childbirth, and primarily occur because of the thinning of vaginal tissues, a common result of decreased estrogen levels. This thinning makes the vaginal tissue more susceptible to injury, particularly during sexual intercourse. While penetrative sex is a frequent cause of these lacerations, or tears, in menopausal women, other factors, like inserting foreign objects into the vagina or physical activities causing straddle injuries, can also lead to tears. Additionally, scarring from previous surgeries may exacerbate the risk.
Symptoms of non-obstetric vaginal lacerations in menopausal women often include discomfort or pain during sexual activities or urination and unexpected bleeding separate from menstrual cycles. Visible signs might include redness or swelling in the vaginal area and a burning sensation or itchiness near the affected region. Any unusual discharge could indicate an infection.
The severity of these tears can vary. Minor tears may cause slight pain and light bleeding, typically healing with minimal intervention. However, more significant tears, characterized by intense pain or heavy bleeding, require medical treatment, potentially including surgery. Prompt medical attention is essential to prevent complications and maintain vaginal health during menopause.
How is it diagnosed?
Diagnosing menopause-related vaginal and vulval changes commonly begins with a detailed medical and sexual history, complemented by a comprehensive physical examination. The physical examination focuses on signs of vulvovaginal atrophy, such as thinning of the vaginal walls and decreased elasticity. They may also inspect for any visible abnormalities in the vulva and vagina, including patchy skin or signs of POP.
A pelvic examination is essential in assessing pelvic floor dysfunction and POP. This examination may involve observing a woman’s response to certain maneuvers like coughing or straining to evaluate better the strength and functionality of the pelvic floor muscles. For symptoms like unusual vaginal discharge, a sample may be taken for laboratory analysis to check for infections or other abnormalities. In cases of non-obstetric vaginal lacerations, the healthcare professional will assess the severity and extent of the tear.
Additional diagnostic tests may include vaginal potential of hydrogen (pH) testing to evaluate changes in vaginal acidity, vulval skin biopsies to rule out dermatological conditions, a pap smear to rule out cervical dysplasia or cancer, and imaging techniques like ultrasound or magnetic resonance imaging (MRI) to assess the pelvic region for structural abnormalities or issues related to POP.
Sharing details about your lifestyle, medication use, related symptoms, and any self-care measures provides a comprehensive view of your health. This information helps healthcare professionals understand the full scope of the symptoms and their impact on your life and rule out other conditions that could cause similar symptoms, such as infections, dermatological conditions, or hormonal imbalances.
How is it treated?
Treatment for menopause-related vaginal and vulval changes involves a multifaceted approach tailored to each woman’s specific symptoms and health profile.
Hormone Replacement Therapy (HRT) in the form of low-dose vaginal products with estrogen, or local estrogen in vaginal tablet, cream gel, or ring pessary form, can help replenish estrogen levels, thereby treating symptoms like vaginal and vulval dryness, itching, and discomfort. v Antibiotics are used to kill harmful bacteria where there is inflammation or infection. Topical corticosteroids treat skin changes and discomfort, and antifungal creams or suppositories for yeast infections. Pain medication, like nonsteroidal anti-inflammatory drugs (NSAIDs), may be required, or antihistamines, to help with itching.
Medical devices such as a pessary can help hold a sagging organ in place for POP. In more severe cases, obliterative and reconstructive surgical procedures may be performed. Surgical procedures for non-obstetric vaginal lacerations include vaginal reconstruction and vaginoplasty, depending on the severity of the tear. Laser therapy for vaginal rejuvenation is a non-invasive technique that can help induce collagen remodeling, and synthesis and elastin formation to improve vaginal elasticity.
Conventional therapies, such as pelvic floor physical therapy, can help strengthen muscles, help scar tissue move more easily, and treat symptoms related to pelvic floor dysfunction and POP. Natural therapies such as biofeedback can be used in conjunction with pelvic floor, or Kegel exercises by providing concurrent feedback on muscle tone, helping to improve accuracy in performing exercises, and helping to reduce symptoms. Hypnotherapy may also be beneficial in treating severe pain.
Dietary supplements like vitamin D (ergocalciferol (D2) and cholecalciferol (D3)), Omega-3 fatty acids, found in fish oil supplements, and probiotics, especially lactobacillus strains, are associated with maintaining healthy vaginal tissues, supporting vaginal health, and maintaining healthy vaginal flora, respectively. Phytoestrogens, plant-based compounds that mimic estrogen in the body, can be an alternative to HRT.
Products such as vaginal moisturizers can help ease vaginal dryness, as can topical hyaluronic acid and vitamin E in suppository and topical form. Washing or moisturizing with medical emollients can relieve dryness and itchiness. Vaginal lubricant and warming lubricant can decrease discomfort and increase pleasure during sexual activities. Devices such as vaginal dilators can relax tight vaginal muscles, help widen and lengthen the vaginal opening, improve the production of natural lubrication, and re-strengthen weak pelvic floor muscles. Pelvic floor, or Kegel, wands, and weights help access hard-to-reach pelvic floor muscles.
The effectiveness of these treatments varies among individuals and should be discussed with a healthcare professional.
How is it managed?
Menopause-related vaginal and vulval changes can be managed through lifestyle modifications, and focused attention on prevention, hygiene, and strengthening the pelvic floor.
Adopting a positive mindset and using stress reduction techniques, such as meditation, yoga, and mindfulness practices, can help manage the psychological aspects of symptoms. Ensuring a comfortable home environment, free from irritants that could exacerbate symptoms, is also beneficial.
A balanced diet rich in phytoestrogens, vitamins, and minerals supports overall vaginal health. Foods high in Omega-3 fatty acids, like fish, and flaxseeds, and those rich in antioxidants, can be beneficial. Probiotics and yogurt with live cultures can help maintain a healthy vaginal flora. Avoiding irritants like spicy foods, caffeine, and alcohol, which can aggravate symptoms, is also advisable.
Regular physical activity improves blood flow and overall well-being, which can positively affect vaginal health. Exercises focusing on the pelvic floor are recommended while avoiding activities that put excessive pressure on the pelvic area. Exercise helps improve sleep, which is vital for overall health. Establishing a consistent sleep routine, sleeping in a cool room, and using breathable bedding can help to attain a deep sleep.
Maintaining healthy relationships and social interactions can provide emotional support. Open communication with partners about sexual health and vaginal and vulval changes can help in a more understanding and fulfilling sexual relationship.
For sexual health, using lubricants and moisturizers can ease discomfort during intercourse. Condoms can help prevent new organisms from entering your vagina. Being sexually active promotes healthy blood flow and natural lubrication, reducing discomfort and irritation. Avoiding products that irritate the vaginal area, such as scented soaps, toilet paper, or sanitary products, as well as douches (devices used to wash the vagina), helps in both prevention and further aggravation, as does keeping your vaginal area dry. Wearing cotton underwear and loose clothing helps your vagina and vulval area breathe. Cold packs or ice packs can help ease burning. Also, reducing smoking is recommended as it reduces blood circulation, which can directly affect vaginal lubrication since lubrication relies on increased blood flow to the vagina.
Changes to the vagina and vulva occur as the reduction in estrogen leads to thinning and loss of elasticity of vaginal and vulval tissues. The bladder, vestibule of the vulva (containing the urethral and vaginal opening), vagina, and urethra are all affected because of their high levels of estrogen receptors. The reduction in estrogen can cause dryness, discomfort, and pain in these areas. Symptoms include burning, dryness, inflammation, itching, and pain in the vagina and vulva, patchy vulva skin, pelvic issues including POP, vaginal discharge and non-obstetric vaginal lacerations. Following diagnosis, treatment, and management options may include Hormone Replacement Therapy (HRT), medications, topical corticosteroids, medical devices such as a pessary, biofeedback, pelvic floor, or Kegel exercises, probiotics, and dietary supplements.
