Vaginal Anatomy

The vagina is an amazing part of the body that changes with aging just as the rest of your body changes.

During reproductive life, the walls of the vagina are lush, moist, and corrugated. That means they have lots of stretchy folds made from elastic tissues. Think of the sleeves of a sweater or the top of a sock that allows a hand or foot to pass through and then spring back firmly around the wrists or ankles.

Those folds are why the vagina can place gentle pressure on a tampon or a male partner. When a baby is born, the vagina can expand to allow the passage of a baby, and then, once it has some time to recover, it can go back to about the size it was before. Because of the many blood vessels just beneath the surface, the tissue remains lush and moist.

The Role of Estrogen

Estrogen is responsible for most of this moisture and elasticity. Estrogen supports the blood vessels in the walls of the vagina. That’s why the tissue is pink. It also maintains the pH of the vagina, which is a result of an optimum balance of the bacteria in the vagina. A balanced pH helps avoid vaginal infections.

Estrogen also;

• Helps the vagina remain plump, moist, and lubricated during love-making.
• Maintains the lips of the vagina so that their size and color and wetness are optimum.
• Increases the amount of mucus in the cervix at mid-cycle and makes it more watery so that sperm can enter the uterus and gain access to the egg at the time of ovulation. For the remainder of the cycle, when estrogen levels are lower, the mucus in the cervix is thicker and prevents sperm from entering at the wrong time, and prevents bacteria from entering that could cause an infection.
• Supports the strength of the pelvic floor muscles, which help to support the bladder and maintain urine control
• Supports the lining cells of the bladder to control elasticity of the bladder, which also helps control ones urine

Menopause Causes Changes Down There

As a woman approaches menopause, estrogen levels drop steadily and eventually go back down to prepubertal levels. When that happens, all of the above things change:

• The folds of the vagina get flatter and eventually go away. That can make sex uncomfortable
• The secretions the vagina typically produces with intimacy are so reduced it can cause soreness or even pain
• The color of the tissue gets paler, the vagina can narrow and even shorten
• The lips of the outer vagina (labia) get paler, smaller and dryer
• The pH changes and that increases the risk of vaginal infections
• Bulges can sometimes be seen. Either the bladder or the rectum can “drop” causing a visible bulge in the opening of the vagina. This happens because pelvic floor muscles weaken.
• Because testosterone levels also drop as menopause approaches, there may be less hair, and some of it may turn gray

Menopause Can Change the Vagina to Cause More UTIs

After menopause, when the vaginal tissues shorten, they pull back from the urethra, leaving it exposed and more likely to allow bacteria to enter the urinary tract. That leads to more infections with aging. If left untreated, it’s one of the most common causes of UTIs in women beyond menopause.

Treating Vaginal Changes

Treatment of vaginal symptoms in menopause always depends on the cause. Fortunately, there are many treatments available. For a complete discussion, see Chapters 5 and 6 of  The Menopause Guidebook 3rd Edition. But in the meantime, here are some things you should know and consider talking about with your healthcare provider.

Most of the symptoms of vaginal pain and or dryness are improved with vaginal estrogen. It is available as suppositories, tablets, creams or rings inserted into the vagina. Local estrogen is safe and effective in restoring vaginal health for most women. And even if a woman has estrogen receptor positive breast cancer and other treatments have failed, local estrogen has not been found to increase either death or recurrence of the breast cancer according to the American College of Obstetricians and Gynecologists. Small amounts of vaginal estrogen can get into the blood stream initially, but this reduces to negligible amounts in the first few weeks of treatment after the tissues rebuild and gets thicker. Vaginal estrogen has also been shown to help reduce UTIs in menopause because it helps the vaginal tissue to protect the entrance of the urethra. The vaginal estrogen may also strengthen the pelvic floor mucscles and may improve the muscle tone of the bladder.

Systemic estrogen (patch, pills and other forms) are typically used to treat symptoms such as hot flashes. They can also improve vaginal symptoms. Sometimes both vaginal and systemic estrogen are taken together.

However, if you either do not want or cannot take estrogen, there are many other options.

Other prescription treatments include DHEA, which is available as a prescription vaginal suppository. The DHEA breaks down into estrogen and testosterone. Almost all of it stays in the vagina. Another prescription medication for dryness is taken orally. It is called Osphena (ospemifene). It acts like an estrogen on vaginal tissues.

Moisturizers and lubricants:  Over-the-counter vaginal moisturizers and lubricants can help relieve dryness and discomfort during intercourse. They typically do not treat the vaginal dryness or pain. They are symptomatic relief.

Lifestyle changes: Maintaining a healthy lifestyle, including a balanced diet, regular exercise, and avoiding irritants like douches and harsh soaps, and drinking at least 64 ounces of water can also help improve vaginal health during menopause.

Many over-the-counter products are available. None work for everyone, but they might work for you. Try one for a month and if it isn’t to your satisfaction, consider trying another one. A new product on the market is available on the internet and is called Revive moisturizing gel by Secret de Joie. It is FDA approved and derived from algae that produce a substance that balances pH and and prevents them from drying out. Initial reports are promising.

It’s always a good idea to consult a healthcare provider to discuss the best treatment options based on individual symptoms and preferences, and to be sure there is no infection. The vagina will change in perimenopause and menopause. Sometimes that will lead to vaginal dryness and/or vaginal pain. One thing is certain, there is no reason to suffer with vaginal pain or vaginal dryness. There are lots of effective treatments available.