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Symptoms

WHAT IS IT?

Sometimes menopause causes changes to the genitals and urinary system that causes symptoms, called GSM or Genitourinary Syndrome of Menopause and pain with sex is the most commonly described symptom. Vaginal pain may begin during the menopause transition or after menopause. It may be a burning pain, or itchy. Some women have a discharge coming from their vagina. The pain may be constant, or only during penetrative sexual activity. (If the pain is constant, read the section on vaginal pain not during sex.)

Pain during sex may be due to vaginal dryness. Just as our hair, skin, and eyes may become dry during perimenopause, so may our vaginas. If the vagina no longer has enough natural lubricants, sex with penetration can cause irritation, chaffing, itching, or burning.

Pain may also happen because the vaginal feels “too tight” and penetration is painful or impossible. We have specific recommendations for that.

Sometimes the pain and discomfort decrease a woman’s interest in sex. It is important to decrease the pain before trying ways to increase the desire for sex. When you are ready, you can read about low sex drives here.

WHAT’S HAPPENING TO MY BODY?

The vagina and vulva change during perimenopause. The vulva is the area on the outside around the entrance to the vagina. There is less blood flow to the vagina and vulva, and the nerve signals take longer to work. The skin in the vagina and vulva gets thinner and smoother. There is often less natural lubrication to the vagina. Your health care provider may see these changes during an exam. The changes are called “genitourinary atrophy.”  But these changes do not strongly correlate with a woman’s symptoms. Meaning, you may or may not have these symptoms, even if your health care provider sees signs of atrophy.

WHAT TO EXPECT

These problems are more likely as women approach their final menstrual period. They are even more common after menopause when estrogen levels are low. Not all women with the visual signs of changes to the vagina and vulva have these problems.

RESEARCH SHOWS THESE TREATMENTS HELP

TREATMENTS THAT MAY HELP, BUT WE NEED MORE RESEARCH

  Treatments that are inappropriate or have not been studied for this symptom are not listed.

MORE INFORMATION FOR HEALTH CARE PROVIDERS OR THOSE WHO WANT MORE DETAILS

Treatment of the woman with symptomatic vulvo-vagina atrophy (VVA) related to sexual activity can be approached in a stepwise fashion based on the severity of symptoms. Options include nonhormonal vaginal lubricants to be used with intercourse/vaginal sexual activity, long-acting vaginal moisturizers used regularly (several times per week), and regular sexual activity. For symptomatic VVA that does not respond to these initial management approaches, low-dose vaginal ET is an option.

For women with moderate to severe dyspareunia associated with VVA who prefer a nonvaginal therapy, transdermal and oral hormone therapy (HT) as well as ospemifene are options. Some women may already have vaginal constriction or vaginismus limiting vaginal penetration.

Gentle stretching of the vagina with the use of lubricated vaginal dilators of graduated sizes can play an important role in restoring and then maintaining vaginal function. Reinitiating regular sexual activity once vaginal penetration is again comfortable will help to maintain vaginal health. Many women with this condition benefit from referral to pelvic floor physical therapy. Starting vaginal estrogen before initiating vaginal dilatation and/or pelvic floor therapy may facilitate progress.

REFERENCES

Bruyniks N, Biglia N, Palacios S, Mueck AO. Systematic indirect comparison of ospemifene versus local estrogens for vulvar and vaginal atrophy. Climacteric. 2017 Jun;20(3):195-204. doi: 10.1080/13697137.2017.1284780. Epub 2017 Mar 7. PMID: 28267367.

Edwards D, Panay N. Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition? Climacteric. 2016 Apr;19(2):151-61. doi: 10.3109/13697137.2015.1124259. Epub 2015 Dec 26. PMID: 26707589; PMCID:

Franić D, Fistonić I. Laser Therapy in the Treatment of Female Urinary Incontinence and Genitourinary Syndrome of Menopause: An Update. Biomed Res Int. 2019 Jun 4;2019:1576359. doi: 10.1155/2019/1576359. PMID: 31275962; PMCID: PMC6582847.

González Isaza P, Jaguszewska K, Cardona JL, Lukaszuk M. Long-term effect of thermoablative fractional CO2 laser treatment as a novel approach to urinary incontinence management in women with genitourinary syndrome of menopause. Int Urogynecol J. 2018 Feb;29(2):211-215. doi: 10.1007/s00192-017-3352-1. Epub 2017 May 18. PMID: 28523400; PMCID: PMC5780538.

Kagan R, Kellogg-Spadt S, Parish SJ. Practical Treatment Considerations in the Management of Genitourinary Syndrome of Menopause. Drugs Aging. 2019 Oct;36(10):897-908. doi: 10.1007/s40266-019-00700-w. PMID: 31452067; PMCID: PMC6764929.

Lee Y. Patients’ perception and adherence to vaginal dilator therapy: a systematic review and synthesis employing symbolic interactionism. Patient Prefer Adherence. 2018 Apr 12;12:551-560. doi: 10.2147/PPA.S163273. PMID: 29695897; PMCID: PMC5905492.

Lethaby A, Ayeleke RO, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2016 Aug 31;2016(8):CD001500. doi: 10.1002/14651858.CD001500.pub3. PMID: 27577677; PMCID: PMC7076628.

Rahn DD, Carberry C, Sanses TV, Mamik MM, Ward RM, Meriwether KV, Olivera CK, Abed H, Balk EM, Murphy M; Society of Gynecologic Surgeons Systematic Review Group. Vaginal estrogen for genitourinary syndrome of menopause: a systematic review. Obstet Gynecol. 2014 Dec;124(6):1147-1156. doi: 10.1097/AOG.0000000000000526. PMID: 25415166; PMCID: PMC4855283.

Weinberger JM, Houman J, Caron AT, Anger J. Female Sexual Dysfunction: A Systematic Review of Outcomes Across Various Treatment Modalities. Sex Med Rev. 2019 Apr;7(2):223-250. doi: 10.1016/j.sxmr.2017.12.004. Epub 2018 Feb 3. PMID: 29402732.

 Last reviewed: April, 2021

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