Menopause and the vagina: What you should know?

Miyara Women | Feb 24, 2025 | Updated: May 14, 2025 Written by: Dr. Ayshwarya Ravichandran, 10+ years of experience in science communication, women's health advocate

"As soon as I turned 40, along with longer and heavier periods, night sweats and migraines, I also started having itching, particularly in the transitional areas between haired to non-haired skin. I went to see one GYN and his response was basically: yeah, you're getting older. Later, it worsened to tearing and lacerations after the most minor things. I'm so sad, scared and angry about my body and the thought of having to deal with this for the rest of my life, and that no one warned me this could happen and so early."

(Real-life experience. Courtesy: Reddit)

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Genitourinary syndrome of menopause (GSM), also known as vulvovaginal atrophy, is incredibly common among peri- and post-menopausal women. The most common symptoms include vaginal dryness, irritation or itching, and painful sex. Globally, prevalence ranges from 27% to 84% of postmenopausal women. In India, the picture is sharper: a 2025 multicentric cross-sectional study from the Indian Midlife Registry, covering 1,781 women across multiple outpatient centres, found GSM prevalence of 48.5%, with lower urinary tract symptoms affecting 38.2% and vaginal dryness affecting 26.4%. The study's conclusion was unambiguous: GSM remains under-recognised and undertreated in India.

Yet a majority of women suffer in silence, conditioned to believe such discomfort is part of ageing or simply unaware that treatment options exist. Seeking treatment for vaginal atrophy is looked down upon despite debilitating symptoms, pushing women to self-medicate, which may not always be safe or effective. Beyond physical discomfort, these symptoms deeply impact emotional well-being, self-confidence, relationships, and quality of life.

And then there is fear of hormonal treatment. Many women and their families are apprehensive about hormonal options. Here is what you should know: the 2025 AUA/SUFU/AUGS Clinical Guideline on GSM, the most comprehensive clinical guidance on this condition to date, confirms that low-dose vaginal hormone therapy is significantly safer than systemic hormone therapy, and is considered appropriate even for women with high-risk conditions like hormone-sensitive cancers.

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Why Does GSM Occur?

GSM is the manifestation of pelvic changes that occur due to estrogen loss during peri- and post-menopausal phases. Tissues and neurons in pelvic organs, including the urinary bladder, uterus, cervix, vagina, and external genitalia, are estrogen-sensitive. The lack of circulating estrogen causes structural and functional changes, altering the entire pelvic environment.

When the vaginal wall thins with age or hormonal depletion, estrogen receptors on the surface decrease in number and activity, leading to both physical degeneration and reduced estrogen sensitivity.

Alterations in the vaginal mucosa, specifically flattening of the surface and loss of texture, cause a decline in beneficial vaginal bacteria that maintain an acidic pH to keep infections at bay. Changes in the vaginal microbiome allow abnormal bacterial species to flourish, with long-term implications for reproductive health and recurring UTIs. Collagen and elastin production is disrupted, affecting connective tissue integrity and smooth muscle contractility. The secretion of hyaluronic acid, a natural moisturising agent in the vagina, also declines. Nerve distribution in the vagina is directly impacted by estrogen levels as well.

Critically, unlike vasomotor symptoms like hot flashes that improve over time, GSM symptoms are progressive and worsen without treatment. The Fifth International Consultation on Sexual Medicine (ICSM 2024) notes that if treatment is stopped, GSM signs return to pre-treatment levels within approximately 1 month, and symptoms within 3 months. This makes ongoing management, not a one-time intervention, the appropriate clinical approach.

Healthy vaginal surface Thinning of the vaginal wall

Alterations in the vaginal mucosa i.e. flattening of the vaginal skin surface and loss of texture causes a decline in the beneficial vaginal bacteria that maintain an acidic pH to keep infections at bay in a healthy condition. Changes in the vaginal microbiome allow abnormal bacterial species to flourish, which can have long-term health implications on reproductive health. It can also lead to recurrent UTIs.

Collagen and elastin production is disrupted, affecting the integrity of connective tissues and smooth muscle contractility. The secretion of hyaluronic acid, a natural moisturizing agent in the vagina, also declines. The nerve distribution in the vagina is also directly impacted by estrogen levels.

What to Expect

These estrogen-dependent changes can result in a range of vulvovaginal symptoms: loss of fat in the external genitalia causing shrinkage of the labia and vulval opening; reduction in vaginal wall thickness; cracking of the vaginal surface; loss of vaginal rugae (ridges); shortening and narrowing of the vagina due to stiffness; and loss of sensitivity in the vagina and clitoris.

A combination of genital, urinary, and sexual symptoms may occur simultaneously, and their severity can vary with time, activity, and hormonal changes. For some women, vulvovaginal symptoms may start very early in perimenopause even when cycles are regular. Others may experience them at later stages, or not at all.

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How Is GSM Diagnosed?

As many symptoms overlap with other medical conditions, diagnosis can be challenging. GSM is diagnosed based on a combination of urinary and vaginal symptoms and by eliminating other possible conditions.

There is anecdotal evidence that women do not bring up genitourinary symptoms unless specifically asked. Since diagnosis is primarily based on self-reported symptoms, medical history, and physical examination, open conversations with the care provider are critical. In specific cases or when symptoms persist after initial treatment, pH testing, vaginal smear, or microbial culture tests may be prescribed.

How to Prevent or Minimise Symptoms

Avoid using cosmetic products on your genitalia: the vagina is a self-cleaning organ. Genitals and the skin around them can be darker than the rest of your body due to friction and hormonal influence. It is best to make peace with this rather than perceive it as a lack of cleanliness.

Avoid douching, as it can be harmful to the vaginal microbiome and increases the risk of vaginal infections. In case of unpleasant odour or abnormal discharge, consult a gynaecologist.

Exercise the vaginal and pelvic muscles regularly. Orgasms are the most effective way to improve blood circulation and maintain healthy vaginal secretion.

Treatment Options

Water-based lubricants and moisturisers: Available over the counter without a prescription. Products containing hyaluronic acid are particularly effective for mild to moderate vaginal dryness.

Vaginal low-dose estrogen: Pessaries and creams of very low-dose estrogen ensure local action with minimal absorption into the bloodstream. The amount of estrogen that enters circulation is almost negligible, making this option considered safe even for high-risk candidates and as an add-on to systemic HRT.

Vaginal DHEA (precursor of testosterone): Mainly prescribed for women with estrogen-sensitive breast cancer and those already on systemic HRT who still experience genitourinary symptoms or sexual dysfunction.

Ospemifene: Binds estrogen receptors and activates them to provide symptomatic relief.

Light- and energy-based therapies: Laser and radiofrequency options have shown promise in stimulating collagen production and new blood vessel formation in degenerated genitourinary organs. Further research is needed before these become widely available as standard treatment.

Bear in Mind

Menopause symptom management is not part of the medical curriculum in many regions. Many gynaecologists may not be fully equipped to treat persistent genitourinary symptoms and may refer patients to a urogynecologist or endocrinologist with specialised training. It is critical to keep up hope, seek empathetic medical practitioners, and advocate for yourself. Only when there is demand will more doctors come forward to get trained in this specialty.

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About the author

With 10+ years of experience in science communication, Dr. Ayshwarya Ravichandran ensures evidence and science-backed information are conveyed to women in understandable and comprehensible language and visualization. She is also a  passionate women's health advocate engaging the Miyara community in different ways.