After having a baby or hitting your mid-30s, hormone changes can mess with your vaginal health. Often, small changes fly under the radar until they become bigger issues, especially as you approach perimenopause. You might notice you’re running to the bathroom more often, especially at night, which can mess with your sleep. Or you might feel some irritation down there because the vaginal skin gets thinner, whether or not it’s connected to thrush or bacterial vaginosis.

Genitourinary syndrome of menopause – what is it?

In 2014, the term Genitourinary Syndrome of Menopause (GSM) was introduced to replace the older terms such as vulvovaginal atrophy and atrophic vaginitis (1). This term is used to describe a collection of symptoms affecting the health of the genitourinary tract in women during the menopause transition. Symptoms include:

• Vaginal dryness. Frequently, the initial symptom a woman may observe is difficulty with tampon insertion.

• Experiencing irritation or a burning sensation in the vulva. Many women have needed to change their type of underwear to prevent friction and discomfort.

• Dyspareunia. Decreased lubrication, along with reduced elasticity, can lead to discomfort during intercourse. Consequently, many women choose to avoid engaging in sexual activity.

• Decreased arousal. The clitoris plays a crucial role in female orgasm. An overgrowth of the clitoral hood may decrease sensitivity, while retraction can lead to heightened sensitivity to touch. Both conditions can negatively impact arousal and desire, resulting in diminished orgasmic function.

• An increased frequency of urination and nocturia can occur. The reduction of collagen and elastin supporting the pelvic floor may cause urinary leakage during coughing or sneezing (stress incontinence) and also when experiencing an urgent need to urinate (urgency incontinence). (1,2)

  
  

Why does this happen?

It's mainly about oestrogen...When oestrogen dips, over time, the following changes can occur:

·        Loss of fat from the outer lips of the vulva, the labia majora

·        Moist tissues of the vulva and vagina, and the mucosa, become dry with reduced lubrication

·        Elastin and collagen are diminished so that the vagina loses its natural folds and pelvic organ prolapse becomes more likely

·        Shrinkage of the tissues of the vulva leaves the urethra, the entrance to the bladder, more exposed and prone to urinary tract infection

·        The vagina and vulva tissues tear more easily

Risk factors & complications

·        Women who have never given birth vaginally are at higher risk of vaginal atrophy (2)

·        Women who smoke are at higher risk as this can cause reduced oxygen & blood flow to vaginal  tissue (2)

·        Tamoxifen medication can also increase your risk of GSM (3)

What can we do to alleviate this?

Bladder Care

·        Drink lots of water- urine should be pale yellow in colour

·        Limit caffeine and alcohol – these can increase frequency of urination & volume of urine as well as irritate the bladder & urethra

·        Avoid constipation – this can put pressure on the bladder and straining to open the bowels can weaken the pelvic floor (water/fibre/movement/bacteria)

·        Stop smoking – oxygen and blood losses to the area will exacerbate symptoms

·        It is advisable to urinate after engaging in sexual activity. This practice can help prevent the transfer of bacteria from the bowel or vagina to the urethra, the entry point to the bladder. Urinating post-intercourse aids in flushing out these bacteria.

·        After using the toilet, it is recommended to wipe from front to back to prevent the transfer of bacteria from the bowel to the bladder opening.

·        Exercise regularly. This maintains a healthy weight, reduces constipation and can help prevent bladder problems

·        Exercise your pelvic floor. Pilates is good physical exercise that helps to strengthen the pelvic floor muscles. There are also many apps available to motivate and set alerts for you to practice pelvic exercise regimes and learn how to relax the pelvic floor. Breathing exercises can help with this.

Vulva care

To prevent irritation of the sensitive tissues of the vulva, avoid:

- soap/bubble bath/bath creams & oils/shower gels

-        talcum powder

-        cleansing wipes

-        feminine wipes

-        perfumes

-        deodorants

-        antiseptics

-        fragranced washing powders/conditioners/tumble dry sheets

-        panty liners

 ·        Avoid washing too often, once daily is usually adequate and wash with your hands - not flannels which can damage delicate tissue. Gently pat dry, do not rub

After cleansing, apply an unscented moisturizer to the vulva and use a vaginal moisturizer. It is advisable to use natural intimate moisturizers, as they help maintain the acidic pH of the vagina and ensure the proper moisture balance. Vaginal moisturizers can be applied every 2-3 days or more frequently if necessary.

Use a lubricant. Oil based lubricants should be avoided if condoms are being used for contraception

Natural remedies to support Genito-urinary health

-            Phytoestrogens - sometimes listed as isoflavones on ingredients labels

-            Live bacterial strains (S boulardii, Lactobacillus rhamnosus and Lactobacillus reuteri)

-            Caprylic acid

-            D-mannose

-            Topical extra virgin coconut oil

-            Avoid sugar in the diet

-            Eat prebiotic rich foods

Other treatment options

The administration of local oestrogen in the vaginal area is a highly effective treatment for alleviating symptoms of Genitourinary Syndrome of Menopause (GSM), typically showing results after approximately three months. This treatment can be prescribed by a healthcare professional and is generally safe for long-term use in most women. (3) However, if discontinued, symptoms often recur. There are two forms of oestrogen—estradiol and estriol—and multiple application methods available, allowing for a personalized approach to treatment. Topical oestrogen can be accessed through the NHS in the form of pessaries, creams, gels, or a ring and studies show that it is safe for those who have a past cancer diagnosis. (3,4,5)

Vaginal Laser Treatment

Laser therapy utilizing CO2 or Erbium Yag lasers represents a recent advancement in the treatment of GSM, offering potential benefits for women who have not responded adequately to other treatments or for whom alternative treatments are contraindicated. Preliminary studies have indicated improvements in patients; however, long-term data regarding the safety and efficacy of these treatments are still pending. This treatment is not currently offered through the NHS.

References

1 Genitourinary Syndrome of Menopause: Epidemiology, Physiopathology, Clinical Manifestation and Diagnostic. Sarmento ACA, Costa APF, Vieira-Baptista P, Giraldo PC, Eleutério J Jr, Gonçalves AK. 2021, Front Reprod Health., p.15; 3:779398. doi: 10.3389/frph.2021.779398. PMID: 36304000; PMCID: PMC9580828

2 Rubin R., Sanaee M., Yee A., Moyneur E., Dea K., Dury A.Y. (2025), ‘Prevalence of urinary tract infections in women with vulvovaginal atrophy and the impact of vaginal prasterone on the rate of urinary tract infections. Menopause. doi: 10.1097/GME.0000000000002485. Epub ahead of print. PMID: 39774900.

 3 Agrawal P. et al. (2023), ‘Safety of vaginal estrogen therapy for genitourinary syndrome of menopause in women with a history of breast cancer’, Obstet Gynecol,142(3):660-668. doi: 10.1097/AOG.0000000000005294

4 McVicker L. et al (2024), ‘Vaginal estrogen therapy use and survival in females with breast cancer’, JAMA Oncol, 10(1):103-108. doi: 10.1001/jamaoncol.2023.4508

The 2022 hormone therapy position statement of the North American Menopause Society advisory panel (2022), ‘the 2022 hormone therapy position statement of The North American Menopause Society’, Menopause, 29(7):767-794. doi: 10.1097/GME.0000000000002028

5 Hussain I., Talaulikar V.S. (2023), ‘A systematic review of randomised clinical trials – the safety of vaginal hormones and selective estrogen receptor modulators for the treatment of genitourinary menopausal symptoms in breast cancer survivors’, Post Reprod Health, 29(4):222-231. doi: 10.1177/20533691231208473