October 5th, 2023

By Akeira Johnson, MD

INTRODUCTION

Entering menopause and understanding the complexity of associated symptoms can be met with

with uncertainty and frustration. Unless your healthcare professional has spent time

discussing common symptoms and treatment options, it can be difficult to navigate the

constellation of physical changes that lead into and persist after the onset of menopause.

Understanding the changes that occur with vaginal health after menopause can lead to an empowered midlife journey.

In this article, I would like to guide you with a concise discussion of the common vaginal

symptoms and the treatment options available for women entering into and currently in 

menopause.  So that you feel the most empowered to engage in mutual decision-making with your 

healthcare provider, I will proceed sequentially with: 

• A brief understanding of how menopause is related to common vaginal symptoms
• Acute and chronic vaginal symptoms 
• Over-the-counter treatment and prescription treatment options that offer optimal relief for the most bothersome symptoms

What is Menopause?

Menopause is often diagnosed clinically when a woman is no longer menstruating for 1 year

or more. This time is marked by a loss in ovarian function. On average, this process is marked by 

a final menstrual cycle in her early 50’s.  Since the ovaries create most of the estrogen during 

most of a woman’s lifetime, the loss of ovarian function has several sequelae.  An organ that relies 

heavily on estrogen and its production is the vagina.  Before menopause, a well-lubricated, well-

perfused, and elastic vagina is the result of a healthy amount of  estrogen. 

Now that you have the basics of how menopause leads to vaginal symptoms, let’s detail some

common symptoms.

Vaginal Dryness

Probably the most common complaint of the vaginal symptoms associated with menopause. As

mentioned above, a decrease in estrogen will result in changes in the vaginal tissue that respond 

favorably to this hormone in optimal concentrations.  Unfortunately, vaginal dryness is often

assumed to be suffered through after menopause. However, that is just the contrary since you are

likely reading this article to find out how you can achieve relief even if you have been previously

suffering in silence.

Vaginal dryness can be distressing based on how severe symptoms present and/or how rapid the

onset is. Some women experience a gradual onset through their perimenopausal years, while

others may experience an abrupt onset while in menopause. Regardless of the presentation, 

women are entitled to know and choose the treatment option for them.

Expert opinion: “Unlike some other symptoms of menopause, vaginal dryness worsens as

time passes without treatment.”  

Since the vagina responds to estrogen as its main hormonal input, without restoration of this  

hormone to the vaginal tissue, vaginal symptoms often worsen as time goes on.

This can lead to:

• pain with intercourse
• bleeding during and after intercourse
  
• difficulty attaining climax
• decreased sexual desire
• personal and/or relationship frustration and distress.

Expert opinion: “Since vaginal dryness can affect physical sexual wellness, impacts the 

relationship dynamics and impact overall image of postmenopausal women, discussions with 

romantic partners as well as healthcare providers are vital.”

Understanding Postmenopausal Pain During Intercourse

Pain during intercourse was previously known as dyspareunia. This dysfunction has been 

grouped with other pain dysfunctions known as genito-pelvic pain disorders. This is a fancy way 

to categorize pain associated with vaginal penetration. 

Pain with intercourse after menopause is most likely secondary to decreased lubrication and elasticity of the vagina.  It can be located in different areas of  the vagina during sexual activity.  

Pain present during initial penetration may warrant a different treatment than pain that is only 

present with deep thrusting. Women commonly describe the character of the pain as “ripping, 

tearing, burning, sharp, and/or cramping” to name a few. It is not uncommon for the pain to vary 

in severity and duration.

Expert opinion: “When providing a sexual health history in the setting of pain, it is helpful for healthcare providers when patients can explain pain in character and location.”

Chronic Vaginal Inflammation

This is a generic term for acute, chronic, or recurrent vaginal infections and irritation. Once

estrogen declines, there is a shift in the vaginal pH making the environment more basic. The

environment is acidic with optimal estrogen and maintains a balance of healthy bacteria.

A decrease in estrogen results in increased susceptibility of infections by flora (bacteria) that live

comfortably at a higher pH.

Recurrent or hard-to-treat vaginal and urinary tract infections can become a nuisance and  

hygiene issue. Persistent and/or hard-to-resolve vaginal infections can affect intimacy, 

adherence to vaginal treatments, and overall quality of life in some cases. Many treatment 

approaches involve an understanding of how to balance therapy with that of restoring the local 

hormones with maintenance therapy.

Treatment Considerations

It is important to identify the goal of treatment when considering your options. 

Treating pain with intercourse may likely involve more than one treatment regimen [initially] 

compared to treating vaginal dryness if sexual activity is not a goal. It is also important to 

understand that therapy is a long-term maintenance game in most cases. Restoring estrogen to 

the vagina is truly a case of “not using (or applying) it will result in losing it [as it pertains to the 

previous symptoms]. So treatment adherence and commitment are key.

Choosing Local Estrogen Treatment

As previously mentioned, estrogen is what the vaginal tissue primarily has receptors for and will

respond to in restoration when the right preparations are used. 

Since estrogen comes in both local and systemic regimens, it is important to decide with a 

healthcare provider what regimen will best serve your primary and secondary needs. I.e. are you 

also having hot flashes or night sweats that would benefit from a trial of systemic estrogen?

For most vaginal symptoms associated with menopause, local estrogen is a reasonable

consideration for treatment. It has a low systemic absorption rate, its rare side effects are

typically well-tolerated, and it comes in several preparations to choose from.

Estrogen does require a prescription from a healthcare provider. Local forms for vaginal

symptoms can be used as a cream, a tablet, or a ring. There are bioidentical FDA-approved

regimens for those interested in having natural options.

Though there are few contraindications for local estrogen and it is considered the gold standard 

of therapy for vaginal symptoms of menopause, some patients may not be great candidates. 

Some of those situations include:

• Undiagnosed vaginal bleeding
• Those with a history of estrogen-dependent cancer without oncology approval
• Known allergy to estrogen

It is my practice to start with a vaginal cream in patients with moderate to severe symptoms.

Though it is commonly messy and requires scheduled use, it does produce significant symptom 

improvement. 

The tablet may be difficult to start with in cases of moderate to severe symptoms since it requires 

lubrication to dissolve. Prescribing the tablet too soon after the onset of moderate-severe 

symptoms will likely result in an undissolved tablet lying in the vagina and a woman with 

ongoing complaints. 

The same may be true for attempting to place a vaginal ring in a vagina that has reduced 

elasticity and lubrication. Placement may be just as uncomfortable as sexual penetration in a 

reduced estrogen state. Since the estrogen ring is rigid in structure and is meant to stay in place 

for 12 weeks, I like to ensure that it can be placed and held in the vagina comfortably the entire 

time.

Expert opinion: “Consider starting with a local estrogen cream x 12 weeks before transitioning

to a vaginal estrogen tablet or ring option to ensure adequate absorption and future

maintenance.”

Vaginal Moisturizers As Treatment Option

Vaginal moisturizers are the over-the-counter treatment options for vaginal dryness that can

provide maintenance therapy. There are many brand names, but these regimens are typically water

or hyaluronic acid-based. They typically are made to use by local insertion on a scheduled basis to

restore moisture to the vagina. Though this is not the gold standard of treatment as in the

case of local estrogen, these options can provide some relief if used as directed.

Expert opinion: “I often recommend moisturizers in cases where estrogen is contraindicated or

undesired for any reason.”

It is important to understand that this regimen, like local estrogen, is considered maintenance

therapy. Therefore, discontinuation of the regimen will result in a return of symptoms.

https://luvenacare.com

https://www.womenshealthcaresolutions.com/menopause

Vaginal Lubricant Selection

When used for vaginal symptoms, it is commonly used on an as needed basis to improve lubrication. This can assist with vaginal penetration and/or thrusting when there is not enough natural lubrication. With estrogen loss, this temporary option is often used in addition to maintenance therapy. The choices are extensive and should optimized based on the severity of symptoms. Ie although a water-based lubricant may not be adequate for a woman experiencing severe vaginal atrophy, a silicone-based lubricant may be a better starter option. 

For the most benefit from a lubricant, it is important to consider its application. I often advise on a generous application during foreplay in preparation for vaginal penetration.  Reapplication after thrusting activity has started is just as important to provide additional comfort with ongoing penetrative and thrusting activity. 

Use of a lubricant can be introduced manually or with an applicator. If intimacy involves penile-vaginal penetration, I advise applying a generous amount to the vaginal opening, the internal vagina if there is an applicator available, the head and shaft of the penis.

Finding a way to balance communicating your needs for comfort during intimacy and remaining present in what you are physically experiencing is key. This may take practice and should be given patience as you navigate this space of treatment implementation.

Mindfulness Of Sexual Wellness

If the above treatment plans sound complex, try not to feel intimidated or overwhelmed.  I am here to assure you that healthy sexual desire after menopause is not only possible, but sustainable. Making this a routine practice or incorporating it in spontaneous activity by spending mindful moments to invest in your sexual wellness will result in a pleasurable pay off.

Spending an increased amount of time engaging in pain-free intercourse and confidently reaching climax will naturally result in an increase in desire.

I can confidently say that desire after menopause is not only possible, but sustainable.

Talking To Your Romantic Partner(s)

Speaking with your partner about symptoms and changes in physical health is important. Having in-depth communication with your partner(s) about symptoms affecting intimacy may offer you the support you need in seeking professional evaluation, agreeing, and adhering to treatment.

Intimacy without effective communication can limit the peak pleasure potential. If you are feeling discomfort chronically or acutely, the last option you want to consider is to “just deal with it”. Your partner may know you [and your body] well, but menopause symptoms may present a new opportunity to renew how communication surrounding intimacy takes place for you and with your partner(s).

Talking to a Healthcare Provider

“Vaginal health is not purely sexual, but it is also an opportunity to address your gender-specific wellness needs comprehensively.“ –ALJ, MD

It is important to understand that none of the above symptoms have to be your new normal. With this information, I hope to empower your awareness of change associated with menopause.  The transformation that is common in the midlife and beyond should be openly discussed just as much as it is validated.  The communication you have with your healthcare provider about vaginal symptoms after menopause creates an opportunity to honor what your entire body needs during this transition.

Speaking with your healthcare provider not only allows you the chance to make an informed decision about treatment options, but should also offer you the opportunity to feel supported through your wellness journey.