Vaginas Age, Too: Painful Sex After Menopause and How to Find Relief

Vaginal concerns are one of the primary concerns that bring women to the clinic.   Their concerns run the gamut from painful sex, itching, burning, dryness, and changes in discharge.  Most of us have experienced a yeast infection or bacterial vaginosis over the course of our lives, but there are a host of other issues that can arise, particularly with aging, that are less known or talked about. 

This is what I hear: 

“It feels like there are shards of glass cutting me.”

“It hurts to just sit.”

“I feel like I always have a urinary tract infection.”

“I don’t want to have sex because sex hurts.”

“I itch.  It’s so bad at night I wear socks on my hands to stop myself from scratching myself raw.”

The vagina is a mucous membrane like the mouth or the inside of the eyelid.  All mucous membranes, including the vagina, are affected by hydration, the adequacy of water in the body. The vagina is also affected by hormones, in particular, estrogen.  

Estrogen levels fluctuate throughout the menstrual cycle in women who are menstruating and decline with age.  Estrogen affects the suppleness and elasticity of the vagina as well as the pH.  The decline in suppleness and elasticity can reduce the vagina’s normal stretchiness and may predispose to trauma or even tearing of the vaginal tissue.  A change in vaginal pH can create an environment in which pathogens are likely to grow.  This is why menstruating women may notice a flare of their vaginal symptoms premenstrually when hormone levels decline.  

With age, vaginal penetration can become more difficult particularly if penetration does not occur regularly.  If nothing enters the vagina, it can be hard to put anything into the vagina.  Women looking to have penetrative sex who haven’t had it for a period of time may benefit from the use of vaginal dilators.  Vaginal dilators retrain the vagina in how to stretch.  Local peeps looking for vibrators and dilators can check out Nomia Boutique in Portland, Maine.

Physical stretching is one issue and lubrication is another.  Vaginal lubrication also diminishes with age and lower estrogen levels in vaginal tissue.  For some women, over-the-counter vaginal lubricants are sufficient to permit the “slip and slide” desired for vaginal penetration, but to regain elasticity, estrogen is the treatment of choice.  Vaginal estrogen, as opposed to systemic estrogen, often suffices and comes in creams, tablets, rings, and compounded suppositories.  Improvement to vaginal tissue with estrogen use continues for up to two years, which is to say, there’s help to be had and it gets better and better.

The labia, both minora and majora, may appear smaller with age, as might the clitoris.  Vaginal estrogen and/or testosterone can remedy this.  For women who are estrogen-weary, vaginal hyaluronic acid is a non-hormonal alternative.  Testosterone is not FDA approved for treatment in women in the United States, but many practitioners prescribe it and ISSWSH (the International Study for Women’s Sexual Health) did develop an evidence-based protocol for the use of testosterone in women.

Lichen sclerosis causes itching, particularly around the clitoral hood and the anus, and in general, the itching is worse at night.  Women often report wearing socks on their hands to prevent themselves from itching themselves raw while they sleep.  The affected tissue appears thick and white.  Lichen sclerosis is seen in maternal lines and is often associated with hypothyroidism. Lichen is autoimmune in nature, which means the root cause resides in the gut.   Steroid cream works well for symptom management, but getting to the root cause entails identifying inflammatory foods and healing the gut microbiome.  

One last word on GUM, or genitourinary syndrome of menopause, which involves the vagina and the urinary tract.  GUM “is a new term that describes various menopausal symptoms and signs, including not only genital symptoms (dryness, burning, and irritation), and sexual symptoms (lack of lubrication, discomfort or pain, and impaired function, but also urinary symptoms (urgency, dysuria, and recurrent urinary tract infections).” J Menopausal Med. 2015 Aug; 21(2): 65–71.  Lots of times, menopausal women think they have a UTI, when the problem is, in fact, GUM.

Like all parts of the body, the vagina ages, too.  Everything is connected to everything.  There is a lot that can be done to leverage against the more uncomfortable physical experiences that occur due to aging.  The key is in doing that part that is ours to do, not writing off our concerns because we are “just getting old,” and finding creative, experienced practitioners who can help solve the challenges.