The decrease in oestrogen levels during menopause can impact a woman’s reproductive and urinary health.
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Genitourinary Syndrome of Menopause (GSM) refers to a collection of symptoms and signs related to the changes in the genitourinary tract that occur during and after menopause. It is a more comprehensive term that encompasses the previously used term "vulvovaginal atrophy" and includes a broader range of symptoms associated with oestrogen deficiency.
During menopause, oestrogen levels drop, which can affect various tissues in the genitourinary system. The genitourinary tract includes the vagina, vulva, urinary bladder, and urethra. This decline in oestrogen can lead to thinning and dryness of the vaginal walls, loss of elasticity, and changes in the pH of the vagina.
These physical menopause symptoms can be distressing and impact your day-to-day life. They can also affect your overall well-being and it's common for these physical changes to have a knock-on effect on your mood, emotions and confidence.
In this article, we explore the common vulval, vaginal and urinary changes during menopause and discuss treatment options for GSM.
Common vaginal changes during menopause
There are many genitourinary symptoms of menopause. Not all women will experience these symptoms and when they begin and how severe they are can vary significantly between individuals.
Vaginal atrophy
Vaginal atrophy occurs as a result of reduced oestrogen production in the body. It is characterised by thinner, drier and less elastic vaginal tissue and the vaginal canal can also become shorter and narrower.
Vaginal atrophy can cause itching, burning, inflammation and discomfort which can make urinating, walking and even sitting down painful. The reduced elasticity can also make the vaginal tissues more fragile and prone to tearing, which can cause spotting, particularly after sex.
Painful sex
The decline in oestrogen levels during menopause leads to a reduction in natural lubrication. This can cause vaginal dryness, making sexual intercourse uncomfortable or even painful (dyspareunia).
The thinning of the vaginal lining can also contribute to pain. Over time, a lack of sexual activity can worsen vaginal atrophy, leading to a cycle of pain during sex and avoidance of intercourse.
Urinary incontinence
Menopause can weaken the pelvic floor muscles, which support the bladder. This can lead to various forms of urinary incontinence, such as stress incontinence (leakage when coughing, sneezing, or exercising) and urge incontinence (a sudden, intense urge to urinate). The decline in oestrogen can also affect the urethra, further contributing to bladder control issues.
Increased urinary tract infections (UTIs)
Lower oestrogen levels can alter the vaginal and urinary tract environment, reducing the presence of healthy lactobacilli that protect against infections. As a result, women in menopause may experience more frequent UTIs. Thinning of the urethral lining and changes in the vaginal pH can also increase susceptibility to bacterial infections, as can weakened pelvic floor muscles which make it harder to empty the bladder.
Symptoms of a UTI include:
- Pain or burning when urinating
- Frequent urination
- Waking up at night to urinate
- Passing only small amounts of urine
- Lingering discomfort after urination
Pelvic floor weakness
The drop in oestrogen can weaken the muscles of the pelvic floor, which support the bladder, uterus, and rectum. This can lead to pelvic organ prolapse (where organs like the bladder or uterus drop into the vaginal canal), as well as incontinence issues.
Vulval changes
During menopause, changes in the vulva can make the external parts of your genitalia look different. You may lose some fat tissue from around the genital area which can make your labia look smaller. It’s not uncommon to experience decreased pubic hair growth too.
Further, the skin of the vulva can become thinner, drier, and more sensitive due to reduced oestrogen levels. This can cause itching, burning, and discomfort. Some women may experience a condition called lichen sclerosis, which leads to white, shiny patches on the vulva that can become sore or crack. It may be important to see a doctor to have this condition identified if you feel you may have noticed this change.
Clitoral changes
It is not uncommon to notice changes to your clitoris during menopause. Due to the loss of oestrogen and progesterone, the clitoris can become smaller over time and lose sensation. This can result in sex becoming less pleasurable, a decreased response to clitoral stimulation and orgasm via clitoral stimulation becoming harder to achieve.
Treatment for genitourinary syndrome of menopause
While GSM changes can significantly impact your quality of life, there are various treatment options available to help manage and alleviate symptoms. From hormonal therapies to lifestyle modifications, women can explore a tailored approach to find relief and improve their well-being during menopause.
Hormone replacement therapy (HRT)
HRT is a highly effective treatment for GSM, particularly for women experiencing moderate to severe symptoms. By replenishing oestrogen levels, HRT can restore the thickness and elasticity of the vaginal wall, improve lubrication, balance vaginal pH and reduce urinary symptoms.
HRT can be administered systemically via pills, patches, gels or spray.
Topical oestrogen can also be very effective for GSM, used either alongside systemic HRT or on its own, vaginal creams, tablets, or hormonal ring pessaries are excellent for targeted relief of GSM symptoms.
Water-based lubricants
For women experiencing painful sex due to vaginal dryness, water-based lubricants are a quick and easy solution. They help reduce friction during intercourse, making it more comfortable. However, it’s important to choose products that are free from irritants like fragrances, parabens or glycerine, as these can exacerbate dryness and cause irritation.
Topical vaginal moisturisers
A non-hormonal treatment option, topical vaginal moisturisers provide long-lasting hydration to the vaginal tissues, helping to relieve dryness and discomfort. Unlike lubricants, which are used just before sexual activity, moisturisers are intended for regular use to improve overall vaginal moisture.
Lifestyle changes
Making certain lifestyle adjustments can also help manage GSM symptoms:
- Cardiovascular exercise: Regular physical activity boosts blood flow, including to the pelvic area, which can improve tissue health and sensitivity.
- Stopping smoking: Smoking accelerates the decline in oestrogen levels and reduces blood flow, exacerbating GSM symptoms. Quitting can help improve vaginal and urinary health.
- Avoiding vaginal irritants: Products like soaps and bubble baths can irritate sensitive vaginal tissues. Switching to using over the counter emollients often advertised as creams for eczema or dry skin, or coconut oil which can be bought on supermarket shelves for washing in the bath or shower.
Pelvic floor exercises
Strengthening the pelvic floor muscles through exercises like Kegels can improve bladder control, reduce incontinence, and enhance sexual function. Regular pelvic floor exercises can help maintain muscle tone, support the pelvic organs, and improve blood flow, which can alleviate some symptoms of menopause and pelvic discomfort.
How we can help you at Menopause Care
We offer a consultation with a specialist who knows and understands the nuances of genitourinary syndrome of menopause, and the impact it can have on your overall health and wellbeing.
We will discuss your symptoms and history in detail and develop a plan you are happy with and understand.
With your consent, we will liaise with your GP to ensure they are up to date with your treatment plan.
We can arrange for your prescription to be delivered to you quickly and efficiently to start alleviating symptoms as soon as possible.
We will then guide your care for as long as you need and can refer you to a women's health physiotherapist or other specialists where needed.
If genitourinary symptoms of menopause are affecting your well-being and you want tailored guidance and treatment recommendations, book a consultation with a menopause doctor.
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