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Vaginal Atrophy - a Change with Menopause

As women age they will experience changes to their vagina and urinary system largely due to decreasing levels of the hormone oestrogen.

The changes -- which may cause dryness, irritation, itching and pain with intercourse - are known as vaginal atrophy, and affect up to 40% of postmenopausal women. So don't be embarrassed about raising these issues with your doctor!

Unlike some menopausal symptoms, such as hot flushes, which may go away as time passes, vaginal atrophy often persists and may get worse with time.

Atrophy occurs with natural menopause, when menopause is brought on by surgery involving removal of the ovaries, and after treatments for certain medical conditions (see our separate publication Vaginal atrophy after breast cancer).

This leaflet offers some advice for what you can do to maintain the health of your vagina, your vulva (the external genitals) and your urethra (outlet from the bladder).

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Why is oestrogen important for vaginal health?

The vaginal area needs adequate levels of oestrogen to maintain healthy tissue.  

The vagina's epithelium, or lining, contains oestrogen receptors which when stimulated by the hormone, keep the walls thick and elastic.

When circulating oestrogen decreases, the vaginal lining becomes thinner and drier.

A healthy vagina is naturally acidic, but with menopause it may develop a higher pH (become more alkaline) which leaves women more susceptible to urinary tract infections.

The vulval area also changes with ageing, as fatty tissue reduces and the labia majora (outer lips of the vagina) and the hood of skin covering the clitoris may contract. If sensitive areas become more exposed, chafing can occur.

Pelvic floor muscles become weaker and urination may become more frequent and difficult to control.

What symptoms occur with vaginal atrophy?

  • Irritation, burning, itching, chafing or other discomfort.
  • Dryness due to decreased vaginal secretions which may also mean sexual intercourse becomes uncomfortable or painful.
  • Light bleeding, because the vagina may injure more easily.
  • Inflammation, known as atrophic vaginitis, which can lead to pain on urination and infection.
  • Persistent, smelly discharge caused by increased vaginal alkalinity (higher pH) which is sometimes mistaken for thrush.

How can I minimise irritation to the vagina?

  • Wear underpants made of natural fibres such as cotton and change them daily. Consider going without undergarments when possible e.g. going to bed.  
  • Avoid, or at least limit, time spent wearing tight-fitting undergarments, pantyhose, jeans or trousers as this may lead to sweating.  Also limit time in damp or wet bathers or exercise clothing.
  • Wash clothing with non-perfumed or low-allergenic washing products.  Avoid use of fabric softeners.  Consider second-rinsing if symptoms persist.
  • Avoid use of feminine hygiene sprays and douching. Avoid pads, tampons and toilet paper which are scented.
  • Avoid shaving or waxing the genital area, particularly if irritation is present.
  • Gently wash skin of the genital area only with plain water. Or, use soap alternatives such as Cetaphil, QV wash or Dermaveen and avoid soap, liquid soap, bubble bath and shower gels. Always pat dry (don't rub).
  • You can continue to be sexually active and in fact it may improve your symptoms.  Sexual activities, whether with a partner or masturbation, improve blood flow and help maintain healthy tissue. Consider using a vaginal lubricant or moisturiser (see treatments, below).
  • Practice safe sex, unless in a mutually monogamous relationship, in order to reduce genital infection.
  • Quit smoking.  Smoking increases atrophy by decreasing blood flow to the genital area and directly affecting vaginal cells, as well as threatening your overall health.

What treatments are available?

  • Cool washes or compresses may help itching and mild discomfort. Dissolve half a teaspoon of bicarbonate of soda in 1 litre of water and apply gently with a cloth a few times a day. Softly pat dry. Avoid scratching and keep the area cool and dry. See your doctor if symptoms persist or if they get worse with this treatment.
  • Vagisil cream comes with a pH testing kit and may offer relief for itching and dryness. However it is not generally recommended because local anaesthetic creams may cause irritant or contact dermatitis of the vulva.
  • Vaginal moisturisers can plump up cells in the vagina. One of the most popular nonhormonal preparations is Replens, a low pH gel which comes with an applicator.
  • Vaginal lubricants, such as Sylk or K-Y Jelly, may reduce friction and so make intercourse more comfortable. In some women K-Y Jelly stings because of alcohol/preservatives. Water-based lubricants can be used safely with latex condoms. However oily lubricants should never be used with latex condoms.
  • Natural oils--such as sweet almond or avocado--may help, but some oils and creams--such as tea-tree oil and paw-paw ointment--can cause contact dermatitis, increasing itchiness and discomfort.
  • Vitamin E, either taken orally or applied topically (as ointment) can reduce symptoms.
  • Phyto-oestrogens such as Phyto-Soya are used by some women but evidence for their effectiveness and safety is lacking.
  • Pelvic floor relaxation exercises may help and seeing a pelvic floor physiotherapist who may offer advice on the exercises and techniques to make penetration easier.

Prescription treatments

  • Seek medical advice if you have persistent symptoms as it is important to receive a correct diagnosis. Your doctor will examine you and take a medical history. You may need a prescription medication.
  • Vaginal oestrogen, in the form of pessaries (Vagifem) or creams (Ovestin) inserted with an applicator, can deliver oestrogen to the vagina. As it is not taken systemically (by mouth) it does not carry the same increased health risks, such as breast cancer and stroke, as long term HRT. However it may cause unwanted breast pain and vaginal bleeding.
  • If using vaginal oestrogen, you need to insert it regularly in accordance with the instructions regardless of when you have intercourse. Vaginal oestrogen is effective only while you are using it, so you will need to renew your prescription to continue to get the benefit.
  • If taking HRT--tablets, patches or gels--for menopausal symptoms including vaginal atrophy it is important, if you have still have a uterus, to take the oestrogen with progestogen (combined therapy) in order to reduce the risk of developing cancer of the uterus. But if you have had a hysterectomy, oral oestrogen therapy alone is sufficient.
  • If using vaginal oestrogen but not taking HRT then you do not need to take a progestogen because the amount of oestrogen absorbed is so small.
  • Tibolone (Livial) is another oral synthetic hormone therapy which can relieve symptoms. (Note: Livial is not available in New Zealand).

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Note: Medical and scientific information provided and endorsed by the Australasian Menopause Society might not be relevant to a particular person's circumstances and should always be discussed with that person's own healthcare provider.

This Information Sheet may contain copyright or otherwise protected material. Reproduction of this Information Sheet by Australasian Menopause Society Members and other health professionals for clinical practice is permissible. Any other use of this information (hardcopy and electronic versions) must be agreed to and approved by the Australasian Menopause Society.

Content Updated 15 August 2009