Vulvar and Vaginal Changes During Menopause: What to Expect

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You may be aware that vaginal irritation during menopause can be an issue. What many women don't realize, however, is that the physiological and hormonal changes that occur during perimenopause and menopause can affect a woman's vulvovaginal health as a whole, not just her vagina.

Vulvovaginal atrophy is a condition caused by decreased levels of estrogen, which can affect the feeling and function of both the vulvar and vaginal tissues. And though it isn't often openly discussed, it's very common, affecting an estimated 50% of menopausal women.¹ Here's a closer look at how hormonal changes during perimenopause and menopause can affect your vulva and your vagina, and the steps you can take to feel more comfortable.

Vulva vs. Vagina: What's the Difference?

While it's common for the vulva and vagina to be referred to interchangeably, the two are actually different parts of the body and can potentially experience different symptoms during perimenopause and menopause.

• The vulva is the external area of the female genitals. It includes the opening to the vagina, the opening to the urethra (where urine comes out of), the labia, the clitoris, the perineum (the area in between the vaginal and anal openings) and the mons (the fleshy mound of tissue over the pubic bone).
• The vagina is the internal canal of the female genitals. A long, stretchy tube, the vagina connects the vulva to the cervix. The vagina is where penetrative sex occurs, and it's also the place through which menstrual blood exits the body.²

During perimenopause and menopause, many women experience changes to both their vulvar and vaginal tissues that can cause discomfort or potentially increase the risk for infection.

Vulvar Changes in Menopause

Perimenopause and menopause bring about a sharp reduction in the hormone estrogen. This can cause external vulvar tissues to become thinner, drier, and more prone to irritation. As a result, it's more common to experience feelings of discomfort or stinging, especially during sex.

The vulva can start to look different as well. Many women notice that the skin on the outside of their genitals may take on a pale or shiny appearance.³ If the vulvar tissues become irritated, they might look red or show signs of petechiae - small, purple-brown bumps caused by bleeding under the skin as a result of inflammation.⁴ The labia may also appear flatter and less plump.

Vaginal Changes in Menopause

The same hormonal shifts that can affect the vulva often affect the vagina, too. Like the vulva, decreased estrogen can cause the walls of the vagina to become thinner, drier, tighter and more prone to inflammation. At the same time, the pH of the vagina becomes less acidic, resulting in a loss and imbalance of good bacteria.⁵

Together, these changes can lead to symptoms like burning, itching or irritation, painful sex, changes in vaginal discharge, as well as pain during urination or having to urinate more often.⁶ This drop in good bacteria, too, can set the stage for more frequent vaginal infections, including BV (bacterial vaginosis) and  yeast infections.⁷

Many women mistakenly believe that the vulvar and vaginal discomfort that develops during menopause is just a normal part of aging - in other words, something they have to live with. But the symptoms are actually a sign of a common condition called vulvovaginal atrophy (sometimes called genitourinary syndrome of menopause (GSM), vaginal atrophy or atrophic vaginitis). And though it can't always be prevented, it can be managed.⁸

Managing Vulvar and Vaginal Discomfort in Menopause

If you're experiencing vulvovaginal irritation, you should first bring it up with your healthcare provider. While vulvar and vaginal discomfort or urinary issues are often the result of hormone changes caused by menopause, other culprits can be at play. A thorough examination and discussion of your symptoms can help your provider gain a better understanding of what's going on and allow them to rule out other possible health problems.⁹

Easing vulvar and vaginal symptoms caused by menopause often calls for a multi-pronged approach. Even if you're looking to avoid hormone-based therapies, together you and your provider can discuss treatment options, like lifestyle changes and supplements and come up with the right plan for you.  Vaginal moisturizers or lubricants, for instance, can help restore moisture to vaginal tissues, making sex more comfortable. 

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Engaging in regular sexual activity can make a difference too. Avoiding sex after menopause can actually cause the vagina to become shorter and narrower, causing sex to be more painful if and when it does happen. Having sex more often (solo or partnered) is crucial for encouraging healthy blood flow to the vaginal tissues. That, in turn, keeps tissues stretchier and more lubricated, which can make intimacy more comfortable.¹⁰

Vulvar and vaginal changes during menopause are common but shifting hormones don't have to make you uncomfortable. By understanding how perimenopause and menopause can affect your vulvovaginal tissues, you can work with your provider to find solutions that help you feel good.

Resources

1. https://www.mayoclinicproceedings.org/article/S0025-6196(11)60314-5/fulltext
2. https://www.plannedparenthood.org/learn/health-and-wellness/sexual-and-reproductive-anatomy/what-are-parts-female-sexual-anatomy
3. https://www.menopause.org/for-women/sexual-health-menopause-online/changes-at-midlife/changes-in-the-vagina-and-vulva
4. https://www.mayoclinicproceedings.org/article/S0025-6196(11)60314-5/fulltext
5. https://www.menopause.org/for-women/sexual-health-menopause-online/changes-at-midlife/changes-in-the-vagina-and-vulva
6. https://jamanetwork.com/journals/jama/fullarticle/2614191
7. https://medlineplus.gov/ency/article/004016.htm
8. https://www.mayoclinic.org/diseases-conditions/vaginal-atrophy/symptoms-causes/syc-20352288
9. https://www.menopause.org/for-women/sexual-health-menopause-online/changes-at-midlife/changes-in-the-vagina-and-vulva
10. https://www.mayoclinic.org/diseases-conditions/vaginal-atrophy/symptoms-causes/syc-20352288