Vaginal atrophy and genitourinary syndrome of menopause

Vaginal atrophy is the thinning, drying and loss of elasticity of the vaginal and vulvar tissue that happens when estrogen levels fall, most commonly after menopause. Because the same changes also affect the urethra and bladder, doctors now usually call it genitourinary syndrome of menopause, or GSM. It is very common, tends to get worse without treatment, and responds well to both non-hormonal and hormonal options.

What changes in the tissue

Estrogen keeps the vaginal lining thick, folded and elastic. It supports blood flow, natural moisture and the lactobacilli bacteria that keep the vagina acidic. When estrogen falls:

• the lining becomes thinner, paler and more fragile
• natural lubrication decreases
• the vagina can become shorter and narrower, and less able to stretch
• the pH rises, which makes some infections more likely
• the tissue around the urethra and bladder changes in a similar way

These changes happen gradually. Some women notice them in perimenopause, others years after their last period.

Symptoms

Symptoms fall into three groups, and many people have a mix:

Vaginal and vulvar

• dryness, burning or itching
• soreness or a raw feeling, sometimes even without touch
• discharge that is thin, watery or occasionally yellowish

Sexual

• pain during penetration
• reduced natural lubrication during arousal
• light bleeding or small tears after sex
• less sensation or reduced arousal

Urinary

• needing to pass urine urgently or often
• burning when passing urine
• recurrent urinary tract infections
• leaking

Because these symptoms overlap with thrush, infections and skin conditions such as lichen sclerosus, an examination is the best way to confirm what is going on.

Who is affected

Estimates suggest that around half of postmenopausal women experience GSM symptoms, yet many never mention them to a doctor. Besides natural menopause, it is common after:

• surgical removal of the ovaries
• chemotherapy or pelvic radiotherapy
• hormone-blocking treatments for breast cancer
• some medications that lower estrogen, such as treatments for endometriosis
• breastfeeding, in a temporary form

Effect on sex and intimacy

Pain during penetration is often the symptom that brings people to seek help, and it can affect desire, relationships and self-image. When sex hurts, the pelvic floor muscles can begin to tighten in anticipation, which adds a muscular layer to the pain. The guide to painful sex after menopause covers this in more depth, including ways to reintroduce touch comfortably.

Treatment options

Treatment usually builds in steps, and many people combine more than one approach.

Lubricants and vaginal moisturizers

For mild symptoms, a good lubricant during sex and a vaginal moisturizer used every two or three days can be enough. Products with low osmolality and a vagina-friendly pH tend to be better tolerated by thinner tissue. The guides on how to choose a lube and hyaluronic acid lube and moisturizers explain what to look for.

Vaginal estrogen

Low-dose estrogen applied directly to the vagina, as a cream, tablet, pessary or ring, is the most effective treatment for moderate to severe GSM. It helps the lining rebuild, restores acidity and often reduces urinary symptoms and infections. Because the dose is low and works locally, it is suitable for many women who cannot use systemic hormone therapy. Improvement typically builds over several weeks, and treatment is usually continued long term because symptoms return when it stops.

Other prescription options

For those who cannot or prefer not to use estrogen, doctors may discuss vaginal DHEA (prasterone) or an oral medication called ospemifene, depending on country and medical history. Energy-based treatments such as vaginal laser are being studied, but current evidence is not strong enough for most medical societies to recommend them routinely.

Supporting the pelvic floor

Pain and tissue changes can lead to tight, guarded pelvic floor muscles. A pelvic floor physical therapist can help with relaxation, gentle stretching and, where appropriate, graded use of dilators. More on this is in pelvic floor therapy.

What to expect at an appointment

Many women find it hard to raise vaginal symptoms, and some clinicians do not ask. It can help to write down the symptoms beforehand, including urinary ones, and to say directly that sex has become painful. A GP or gynecologist will usually ask about periods, medication and medical history, and may examine the vulva and vagina to look at the color, moisture and elasticity of the tissue. They may also check the vaginal pH or take a swab to rule out infection. Blood tests are rarely needed to make the diagnosis.

It is also worth mentioning any history of breast or womb cancer, blood clots or other conditions, since this shapes which treatments are suitable. Follow-up after a few months helps check that the chosen treatment is working.

Everyday care

• wash the vulva with water or an unperfumed emollient only
• avoid scented products, douches and panty liners where possible
• wear breathable underwear
• stay sexually active or use self-touch if it feels comfortable, as blood flow supports tissue health

When to see a doctor

See a GP or gynecologist if dryness or pain affects daily life or sex, if urinary symptoms keep returning, or if there is any bleeding after menopause, a lump, ulcer or change in the skin. Bleeding after menopause always needs checking, even if atrophy seems the likely cause. Starting treatment is worthwhile at any age, and there is no need to accept discomfort as an unavoidable part of getting older.