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Vaginal Changes After Menopause
Dr. Phillips is Clinical Assistant Professor and Dr. Bachmann is Professor, Department of Obstetrics and Gynecology, and Professor of Medicine, Interim Chair of Obstetrics/Gynecolgy, Associate Dean for Women's Health and Chief of the OB/GYN Service at Robert Wood Johnson University Hospital, and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.
Menopause brings many unwelcome changes to women's skin. While cosmetic firms, plastic surgeons and women themselves are most focused on the changes happening to their faces — wrinkles, laugh lines, and a thinning and drying of the skin — the same thing is happening to genital tissues. The result is for many women just as unpleasant as facial changes.
During and post-menopause, declining estrogen levels may make sex painful and cause other distressing symptoms such as vaginal burning, irritation, and discharge. Collectively, these symptoms affect both the vagina and the vulva. The problem is known to doctors as vulvo-vaginal atrophy (VVA) or simply, vaginal atrophy.
Roughly half of healthy women over age 60 experience one or more of these symptoms with up to 52% of those affected reporting these symptoms have a negative impact on their quality of life.(1)(2)(3) An international survey of 4,246 women aged 55-65 found 39% of them experienced symptoms of vaginal atrophy. Two-thirds of the women described these symptoms as moderate to severe and 60% found these symptoms to impair their quality of life.(4)
The problem of vaginal discomfort and painful sex is on the upswing as our aging population expands and women live one-third of their life after menopause. Currently, over two million American women reach menopause annually, which translates to approximately 6,000 women per day.(5) Women, as they age, should not only request treatment for medical conditions, but also ask their doctors how to prevent unwanted aging changes. For many, this includes addressing ways to keep the vulvo-vaginal tissue healthy.
Many Are Affected; Too Few Speak Up
Available studies have shown that only 25% of symptomatic women will seek help for VVA, and a large majority of women (77%) are uncomfortable discussing these "personal" symptoms with their health care providers.(6)
Menopausal women are not the only ones who experience VVA. Women of any age who have low estrogen levels may have symptoms. Disorders such as premature ovarian insufficiency, loss of menses from dieting or excessive exercise, surgical removal of the uterus, or prolonged lactation can contribute to women developing symptoms of vulvo-vaginal atrophy. So can medication side effects from cancer drugs and drugs that treat endometriosis;, for example, a GnRh agonist, aromatase inhibitor or chemotherapy.
Doctors can do more to bring the subject up during exams, asking patients directly about painful sex and sexual satisfaction. Women can improve the quality of their lives and sexual well being by being willing to discuss their symptoms with their doctors.
Physiological Changes Behind VVA
Before menopause the tissues — skin — of the vagina and vestibule are much like those covering our bodies. The cells form a strong, elastic, covering. Estrogen helps maintain these vaginal tissues.(7) And the low vaginal pH (2.8 to 4) provides a good acidic environment for normal vaginal flora to thrive, which protect from many vaginal infections.
This environment changes with menopause. Estrogen levels significantly decline,(8) and this plunge in estrogen levels often affects sensitive vaginal and vulvar tissues. The declining estrogen leads to lower vaginal acidity, allowing lactobacilli to colonize the vagina and other microbes to thrive there. Eventually, this much changed vaginal environment results in the unpleasant symptoms of VVA.
The normal level of estrogen improves blood flow to the gentials. If you have less estrogen and therefore less blood flow, your vagina will have fewer secretions, as well as delayed and reduced lubrication with sexual stimulation. The collagen content of the connective tissue also decreases, resulting in decreased elasticity.
The tissues of the vagina, clitoris and labia may thin and become more delicate. In some women, especially those who are not sexually active, the vaginal canal and its entrance may become more narrow.(9)
As women age, these symptoms may become more bothersome. This means that as she ages, a menopausal woman who has had no discomfort or other symptoms may develop troublesome symptoms later.
Ideally, peri- and post-menopausal women should be routinely screened for VVA. The condition is diagnosed based on a woman's history and a physical exam. A blood test is not required.(10)
Your health care provider may initiate a conversation about VVA, since women are often reluctant to do so, but don't wait. You are the authority and treatment can really make a difference.
The typical sorts of symptoms women report include vaginal dryness, burning or itching, and abnormal vaginal discharge. Urinary problems can also occur, such as urinary frequency, urgency or painful urination.
Pain during sex is perhaps one of the main reasons women seek help for VVA. When women experience pain during sexual activity, diminished arousal or decreased desire are often the result.
It would be a mistake, however, to see VVA as only a sexual complaint. As dramatized by actors in our first video “patient-physician” office visit below, even activities ranging from vigorous exercise to simply wearing fitted clothing may elicit vaginal discomfort. (Please note, all the patients in the videos below are actors.)