Vaginal atrophy (atrophic vaginitis) is thinning, drying and inflammation of the vaginal walls due to your body having less estrogen. Vaginal atrophy occurs most often after menopause.
For many women, vaginal atrophy not only makes intercourse painful, but also leads to distressing urinary symptoms. Because of the interconnected nature of the vaginal and urinary symptoms of this condition, experts agree that a more accurate term for vaginal atrophy and its accompanying symptoms is "genitourinary syndrome of menopause (GSM)."
Simple, effective treatments for genitourinary syndrome of menopause — vaginal atrophy and its urinary symptoms — are available. Reduced estrogen levels result in changes to your body, but it doesn't mean you have to live with the discomfort of GSM.
With moderate to severe genitourinary syndrome of menopause (GSM), you may experience the following vaginal and urinary signs and symptoms:
- Vaginal dryness
- Vaginal burning
- Vaginal discharge
- Genital itching
- Burning with urination
- Urgency with urination
- More urinary tract infections
- Urinary incontinence
- Light bleeding after intercourse
- Discomfort with intercourse
- Decreased vaginal lubrication during sexual activity
- Shortening and tightening of the vaginal canal
When to see a doctor
By some estimates, nearly half of postmenopausal women experience GSM, although few seek treatment. Many women resign themselves to the symptoms or are embarrassed to discuss them with their doctor.
Make an appointment to see your doctor if you experience painful intercourse that's not resolved by using a vaginal moisturizer (Replens, Vagisil Feminine Moisturizer, others) or water-based lubricant (glycerin-free versions of Astroglide, K-Y Intrigue, others). Also make an appointment if you have vaginal symptoms, such as unusual bleeding, discharge, burning or soreness.
Genitourinary syndrome of menopause (GSM) is caused by a decrease in estrogen production. Less estrogen makes your vaginal tissues thinner, drier, less elastic and more fragile.
A drop in estrogen levels may occur:
- After menopause
- During the years leading up to menopause (perimenopause)
- After surgical removal of both ovaries (surgical menopause)
- After pelvic radiation therapy for cancer
- After chemotherapy for cancer
- As a side effect of breast cancer hormonal treatment
GSM signs and symptoms may begin to bother you during the years leading up to menopause, or it may not become a problem until several years into menopause. Although the condition is common, not all menopausal women experience GSM. Regular sexual activity, with or without a partner, can help you maintain healthy vaginal tissues.
Certain factors may contribute to genitourinary syndrome of menopause (GSM), such as:
- Smoking. Cigarette smoking affects your blood circulation, resulting in the vagina and other tissues not getting enough oxygen. Smoking also reduces the effects of naturally occurring estrogens in your body. In addition, women who smoke typically experience an earlier menopause.
- No vaginal births. Researchers have observed that women who have never given birth vaginally are more likely to develop GSM than women who have had vaginal deliveries.
- No sexual activity. Sexual activity, with or without a partner, increases blood flow and makes your vaginal tissues more elastic.
Genitourinary syndrome of menopause (GSM) increases your risk of:
- Vaginal infections. Changes in the acid balance of your vagina makes vaginal infections (vaginitis) more likely.
- Urinary problems. Urinary changes associated with GSM can contribute to urinary problems. You might experience increased frequency or urgency of urination or burning with urination. Some women experience more urinary tract infections or incontinence.
Diagnosis of genitourinary syndrome of menopause may involve:
- Pelvic exam, during which your doctor feels (palpates) your pelvic organs and visually examines your external genitalia, vagina and cervix. During the pelvic exam, your doctor also checks for signs of pelvic organ prolapse — indicated by bulges in your vaginal walls from pelvic organs such as your bladder or rectum or stretching of the support tissues of the uterus.
- Urine test, which involves collecting and analyzing your urine, if you have urinary symptoms.
- Acid balance test, which involves taking a sample of vaginal fluids or placing a paper indicator strip in your vagina to test its acid balance.
To treat genitourinary syndrome of menopause (GSM), your doctor may first recommend that you:
- Try a vaginal moisturizer (Replens, Vagisil Feminine Moisturizer, Hyalo Gyn, others) to restore some moisture to your vaginal area. You may have to apply the moisturizer every two to three days. The effects of a moisturizer generally last a little longer than those of a lubricant.
- Use a water-based lubricant (glycerin-free versions of Astroglide, K-Y Touch, others) to reduce discomfort during intercourse. Choose products that don't contain glycerin because women who are sensitive to this chemical may experience burning and irritation. Avoid petroleum jelly or other petroleum-based products for lubrication if you're also using condoms. Petroleum can break down latex condoms on contact.
Bothersome symptoms that don't improve with over-the-counter treatments may be helped by:
- Topical (vaginal) estrogen. Vaginal estrogen has the advantage of being effective at lower doses and limiting your overall exposure to estrogen because less reaches your bloodstream. It may also provide better direct relief of symptoms than oral estrogen does.
- Oral estrogen. Estrogen taken by mouth enters your entire system. Ask your doctor to explain the risks vs. the benefits of oral estrogen.
Vaginal estrogen therapy comes in several forms. Because they all seem to work equally well, you and your doctor can decide which one is best for you.
- Vaginal estrogen cream. You insert this cream directly into your vagina with an applicator, usually at bedtime. Your doctor will let you know how much cream to use and how often to insert it. Typically women use it daily for one to three weeks and then one to three times a week thereafter. Although creams may offer faster relief than do other forms of vaginal estrogen, they can be messier.
- Vaginal estrogen ring. You or your doctor inserts a soft, flexible ring into the upper part of the vagina. The ring releases a consistent dose of estrogen while in place and needs to be replaced about every three months. Many women like the convenience this offers. A different, higher dose ring is considered a systemic rather than topical treatment.
- Vaginal estrogen tablet. You use a disposable applicator to place a vaginal estrogen tablet in your vagina. Your doctor will let you know how often to insert the tablet. You might, for instance, use it daily for the first two weeks and then twice a week thereafter.
Systemic estrogen therapy
If vaginal dryness is associated with other symptoms of menopause, such as moderate or severe hot flashes, your doctor may suggest estrogen pills, patches or gel, or a higher dose estrogen ring.
Your doctor will prescribe progestin along with estrogen if you haven't had your uterus removed (hysterectomy). Oral progesterone, which is chemically identical to the hormone your body produces (bioidentical), is often preferred. Combination estrogen-progestin patches also are available.
If you don't have a uterus, estrogen alone can be used. Talk with your doctor to decide if hormone treatment is an option for you, taking into account any medical issues and family medical history.
Researchers are working to develop other treatments for GSM because of concerns about the long-term potential for even small doses of estrogen to increase the risk of breast and endometrial cancer.
If you've had breast cancer
If you have a history of breast cancer, tell your doctor and consider these issues:
- Nonhormonal treatments. Try moisturizers and lubricants as a first choice.
- Vaginal estrogen. In consultation with your cancer specialist (oncologist), your doctor might recommend low-dose vaginal estrogen if nonhormonal treatments don't help your symptoms. However, there's some concern that vaginal estrogen might increase your risk of the cancer coming back, especially if your breast cancer was hormonally sensitive.
- Systemic estrogen therapy. Systemic estrogen treatment generally isn't recommended, especially if your breast cancer was hormonally sensitive.
Some alternative medicines are used to treat vaginal dryness and irritation associated with menopause, but few approaches are backed by evidence from clinical trials. Interest in complementary and alternative medicine is growing, and researchers are working to determine the benefits and risks of various alternative treatments for genitourinary syndrome of menopause.
Talk with your doctor before taking any herbal or dietary supplements for perimenopausal or menopausal symptoms. The Food and Drug Administration doesn't regulate herbal products, and some can be dangerous or interact with other medications you take, putting your health at risk.
You'll probably start by discussing your symptoms with your primary care provider. If you aren't already seeing a doctor who specializes in women's health (gynecologist or internal medicine women's health specialist), your primary care provider may refer you to one.
What you can do
To prepare for your appointment:
- Make a list of any signs and symptoms you're experiencing. Include those that may seem unrelated to the reason for your appointment.
- Make a note of key personal information. Include any major stresses or recent life changes.
- Make a list of all medications that you take. Include prescription and non-prescription drugs, vitamins and supplements and note the doses.
- Consider taking a family member or friend along. Sometimes it can be difficult to remember all the information provided during an appointment. Someone who goes with you may remember something that you missed or forgot.
- Prepare questions. Make the most of your time with your doctor by preparing a list of questions before your appointment.
Some basic questions to ask include:
- What's the likely cause of my symptoms or condition?
- What are other possible causes for my symptoms or condition?
- What kinds of tests do I need?
- Is my condition likely temporary or chronic?
- What's the best course of action?
- What are the alternatives to the primary approach that you're suggesting?
- I have some other health conditions. How can I best manage them together?
- Are there any restrictions that I need to follow?
- Should I see a specialist?
- Are there brochures or other printed materials that I can have? What websites do you recommend?
What to expect from your doctor
Your doctor will ask questions about your symptoms and assess your hormonal status. Questions your doctor may ask include:
- What vaginal symptoms are you experiencing?
- How long have you experienced these symptoms?
- Do you continue to have menstrual periods?
- How much distress do your symptoms cause you?
- Are you sexually active?
- Does the condition limit your sexual activity?
- Have you been treated for cancer?
- Do you use scented soap or bubble bath?
- Do you douche or use feminine hygiene spray?
- What medications, vitamins or other supplements do you take?
- Have you tried any over-the-counter moisturizers or lubricants?
If you're experiencing vaginal dryness or irritation, you may find relief if you:
- Try an over-the-counter moisturizer (Replens, Vagisil Feminine Moisturizer, others). This can restore some moisture to your vaginal area.
- Use an over-the-counter water-based lubricant (glycerin-free versions of Astroglide, K-Y Intrigue, others). This can reduce discomfort during intercourse.
- Allow time to become aroused during intercourse. The vaginal lubrication that results from sexual arousal can help reduce symptoms of dryness or burning.
Regular sexual activity, either with or without a partner, may help prevent genitourinary syndrome of menopause. Sexual activity increases blood flow to your vagina, which helps keep vaginal tissues healthy.