Vaginal Atrophy: The Dry Truth
Let’s talk dryness down there. Vaginal atrophy, or genitourinary syndrome of menopause (GSM), happens when declining estrogen levels lead to changes in the vaginal and urinary tissues. Think of estrogen like nutrients for those tissues—when levels drop, it’s like a garden not getting watered. The skin might even become thinner, less elastic, and less able to produce natural moisture. This can make the skin itchy, irritated, and dry, making things like sex, pelvic exams, or even sitting too long uncomfortable. The pH level shifts too, allowing fewer “good” bacteria (like lactobacilli) and more irritation-causing microbes to move in, sometimes leading to infections or recurrent BV-like symptoms.
What Actually Happens
Without enough estrogen, the vaginal walls lose their natural plumpness and lubrication. The tissues become fragile and more prone to tiny tears or burning sensations. The rise in pH and drop in lactobacilli mean the protective acidic environment is disrupted - which lays the groundwork for irritation, infection, or urinary issues.
Common Symptoms
· Vaginal dryness or burning
· Pain with sex (dyspareunia)
· Itching, irritation, or rawness
· Spotting during or after sex
· Urinary urgency, frequency, or incontinence
· Recurrent UTIs (urinary tract infections)
When It Shows Up
Most people notice symptoms beginning during the transition into menopause, called perimenopause. They often start before someone’s cycles fully stop, but can get worse with age. It can also happen sooner—during the postpartum period, while breastfeeding, on certain types of birth control (especially progesterone therapy), or after certain cancer treatments. Basically, any time estrogen takes a nosedive, your vagina feels it.
What It Can Lead To
When estrogen levels fall, the vaginal and vulvar tissues lose elasticity, thickness, and their natural lubrication. Weakened tissue and decreased lubrication can lead to irritation and dryness, as well as increased friction during sex, masturbation, or pelvic exams. This extra friction can sometimes cause small tears, trauma, or light bleeding. The skin may feel itchy, raw, or overly sensitive, and daily activities—like wearing tight clothes or wiping after using the bathroom—can become uncomfortable. These changes can also make intercourse less enjoyable or even painful.
Urinary Tract Infections
Lower estrogen also affects the vagina’s microbiome and nearby urinary tissues, which can make it easier for bacteria to sneak up into the bladder. The drop in estrogen raises vaginal pH and reduces lactobacilli (the protective “good” bacteria) allowing pathogens like E. coli to thrive and migrate. As a result, the risk of urinary tract infections increases significantly, with studies showing that up to one in five women over 65 experience at least one UTI each year.
Treatment Options
The good news: it’s totally treatable!
Topical Estrogen: The gold standard. Creams, tablets, or rings deliver estrogen directly to the vaginal tissue, with minimal absorption into the bloodstream. These are a much lower dose than true hormone replacement and are safe for almost everyone. Just talk to your provider first. Topical estrogen not only restores moisture and elasticity but also helps prevent recurrent UTIs by improving tissue health and bacterial balance.
Systemic Hormone Therapy (HRT): If you’re already taking HRT for other symptoms of menopause, it will often help the vaginal symptoms as well. It’s safe to combine vaginal estrogen with this treatment as well.
Vaginal DHEA (Prasterone): Helps restore tissue elasticity and moisture without systemic hormone effects.
Ospemifene (Oral): A medicine called a SERM (selective estrogen receptor modulator). It basically acts like estrogen in vaginal tissue without actually being estrogen.
Vaginal Moisturizers: Used regularly, these help restore the vagina’s natural moisture balance without hormones. We recommend these.
Lubricants: Used during sex, masturbation, or exams as needed. These can be oil-based, silicone-based, or water-based.
Laser Treatments: Sometimes marketed for atrophy, but not well-studied. Data is still mixed, so these aren’t considered first-line therapy for now.
Side Note
It’s not just dryness. When sex hurts or your body doesn’t feel like your own, it affects confidence, intimacy, and identity. You deserve comfort and pleasure—and this is fixable.
Bottom Line
Vaginal atrophy is incredibly common and incredibly under-treated. Whether you’re menopausal, postpartum, or just not feeling like yourself, there’s no reason to suffer in silence. With the right treatment, you can feel comfortable, confident, and at ease again.
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