How Your Vagina Changes in Midlife

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Just as you use lotions to minimize fine lines and hair color to cover gray, you can manage the changes in your vagina, so you don't experience uncomfortable side effects.

This issue is more common than you may think. In a recent HealthyWomen survey, we found that women regularly experience the following vaginal changes:

• 40 percent experience vaginal dryness
• 8 percent experience urinary tract infections
• 12 percent experience vaginal itching
• 25 percent experience painful intercourse

While many women experience these symptoms, a majority of those surveyed (70 percent) were unaware of the condition that may be causing the symptoms: vulvovaginal atrophy (VVA). If you don't understand what's causing the problems, it will be difficult to fix them.

Here is everything you need to know about VVA.

What is VVA?
VVA is thinning, drying and inflammation of the vaginal walls due to your body having less estrogen. It mostly occurs after menopause, but it can develop while breastfeeding or at any other time your body's estrogen production declines.

Causes of VVA
VVA is caused by a decrease in estrogen production. Less estrogen makes your vaginal tissues thinner, drier, less elastic and more fragile. Additionally, the vaginal ecosystem changes. Many of the normal protective vaginal bacteria do not survive as easily, and other bacteria can grow more easily, leading to discharge or odor.

A drop in estrogen levels and vaginal atrophy may occur during these times:

• After menopause
• During the years leading up to menopause (perimenopause)
• During breastfeeding
• After surgical removal of both ovaries (surgical menopause)
• After pelvic radiation therapy for cancer
• After chemotherapy for cancer
• As a side effect of breast cancer hormonal treatment

VVA due to a drop in estrogen levels may begin to bother you during the years leading up to menopause, or it may not become a problem until several years into postmenopause. Although the condition is common, not all postmenopausal women develop VVA. Regular sexual activity, with or without a partner, can help you maintain healthy vaginal tissues.

Symptoms of VVA
With moderate to severe VVA, you may experience the following vaginal and urinary signs and symptoms:

• Vaginal dryness
• Vaginal burning
• Vaginal discharge
• Genital itching
• Burning with urination
• Urgency with urination
• More urinary tract infections
• Urinary incontinence
• Light bleeding after intercourse
• Discomfort with intercourse
• Decreased vaginal lubrication during sexual activity
• Shortening and tightening of the vaginal canal

Don't assume that all vaginal changes during midlife are from low estrogen levels and VVA. Alert your health care provider if you have:

• Any bleeding from the vagina after menopause (that means, it has been more than 12 months since your last period)
• Vaginal itching or irritation (could come from other infections such as yeast)
• Vaginal discharge (may be a sign of other vaginal infections that require specific treatments)
• Urinary frequency, burning or urgency (may signal a urinary tract infection that requires an antibiotic)
• Other pain during intercourse involving the genital skin, vagina or lower abdomen (may come from problems not related to VVA)

How to talk to your health care provider
If you think you may have VVA, it's important to discuss it with your health care provider. Here are some questions you can bring to your appointment:

• What is likely causing my symptoms or condition?
• How can we diagnose my condition?
• What is the best course of action?
• I have some other health conditions. How can I best manage them together?
• Are there any restrictions that I need to follow?

VVA treatment options
After receiving a VVA diagnosis, there are different treatment options available. Some include:

• A nonprescription vaginal moisturizer, which will help restore some moisture to your vaginal area.
• A nonprescription water-based lubricant, which will help reduce discomfort during intercourse.
• Vaginal estrogen therapy that requires a prescription and includes creams, tablets and rings. The doses used for improving your vaginal symptoms are very low and have a much lower risk than the doses used for treating hot flashes.
• Oral non-estrogen therapy that requires a prescription and treats painful intercourse.
• If you are on oral or transdermal estrogen for hot flashes, it may also help your vaginal symptoms. But oral and transdermal estrogen prescription therapies are not recommended for treating VVA alone, if there are no hot flashes.

Ask your health care provider to discuss the risks and benefits of vaginal prescription estrogen therapy or prescription non-estrogen therapy.