Vaginal Dryness & Tissue Changes

What It Is

Vaginal dryness (clinically called vaginal atrophy or genitourinary syndrome of menopause, GSM) is the thinning, drying, and loss of elasticity in vaginal tissues caused by declining estrogen. This isn't just "a little dryness"—it's a structural change in the tissue that affects comfort, sexual function, and urinary health.

50-70% of postmenopausal women experience vaginal dryness, yet only 20-25% seek treatment. Many suffer in silence due to embarrassment, lack of awareness that it's treatable, or belief that it's "just part of aging."

Why It Happens

Estrogen maintains vaginal health in multiple ways:

Estrogen's role in vaginal tissue:

• Maintains tissue thickness: Keeps vaginal walls plump and layered
• Stimulates lubrication: Promotes moisture and natural secretions
• Supports elasticity: Maintains collagen and elastin in tissue
• Regulates pH: Keeps vaginal environment slightly acidic (protective against infection)
• Promotes blood flow: Supports tissue health and arousal response
• Maintains vaginal flora: Supports healthy lactobacilli bacteria

When estrogen declines:

• Vaginal walls thin (atrophy): Fewer cell layers, fragile tissue
• Lubrication decreases: Less natural moisture, longer time to arousal
• pH rises (becomes less acidic): Increases risk of UTIs, yeast infections, bacterial vaginosis
• Tissue becomes less elastic: Tighter, less stretchy, more prone to tearing
• Blood flow decreases: Reduced arousal, slower lubrication response
• Tissue becomes pale and smooth: Loss of rugae (natural folds)

Common Experiences

Physical Symptoms

• Dryness and irritation: Constant dry, itchy feeling
• Painful sex (dyspareunia): Burning, tearing, or sharp pain during penetration
• Bleeding after sex: Fragile tissue tears easily
• Vaginal burning or rawness: Even without sexual activity
• Narrowing of vaginal opening: Tissue contracts, making penetration difficult
• Loss of arousal lubrication: Takes much longer to lubricate, or minimal lubrication even when aroused

Urinary Symptoms (Often Coexist)

• Frequent UTIs: Altered pH and thinned tissue increase infection risk
• Urinary urgency and frequency: Feeling like you need to pee constantly
• Burning with urination: Urethra is also affected by estrogen loss
• Stress incontinence: Leaking with cough, sneeze, laugh, exercise

Impact on Sexuality

• Avoidance of sex: Due to pain, fear of pain, or discomfort
• Loss of sexual confidence: Feeling "broken" or "old"
• Relationship strain: Partner doesn't understand, feels rejected
• Reduced sexual desire: Pain and discomfort suppress libido
• Grief and loss: Mourning the loss of comfortable, pleasurable sex

What Helps

Lubricants (Immediate Relief)

Water-based lubricants:

• Safe with condoms and toys
• Wash off easily
• Examples: Astroglide, K-Y Liquid, Sliquid H2O

Silicone-based lubricants:

• Longer-lasting (don't dry out)
• Silky, smooth texture
• Not compatible with silicone toys
• Examples: Uberlube, Sliquid Silver

Hybrid lubricants:

• Combination of water and silicone
• Good balance of longevity and compatibility

Oil-based lubricants:

• Very slippery, long-lasting
• NOT safe with latex condoms (degrades latex)
• Examples: coconut oil, almond oil
• Can be used for external massage or non-penetrative activities

Important: Lubricants provide temporary relief during sex but do NOT restore tissue health.

Vaginal Moisturizers (Regular Use)

Vaginal moisturizers are applied 2-3 times per week (not just during sex) to restore moisture:

• Hyaluronic acid-based: Replens, Revaree suppositories
• Long-lasting hydration: Absorbs into tissue, lasts 2-3 days
• Restores pH: Some products help rebalance vaginal acidity
• Improves tissue health over time (modest effect)

Moisturizers are better than lubricants alone but still don't fully restore tissue thickness and elasticity.

Vaginal Estrogen (Most Effective)

Vaginal estrogen directly treats the cause by restoring estrogen to vaginal tissue:

Forms:

• Vaginal estradiol cream: Applied 2-3x/week (e.g., Estrace)
• Vaginal estradiol tablet: Inserted 2x/week (e.g., Vagifem)
• Vaginal estradiol ring: Inserted every 3 months (e.g., Estring)

Benefits:

• Restores tissue thickness and elasticity
• Increases natural lubrication
• Restores healthy pH (reduces UTIs)
• Improves comfort and sexual function
• Very low systemic absorption (stays local)

Safety:

• Safe for most women, including many with breast cancer history (discuss with oncologist)
• Minimal systemic absorption (much lower than oral/transdermal HT)
• Does NOT require progesterone (unlike systemic estrogen)
• Can be used long-term

Effectiveness: 80-90% of women see significant improvement within 4-12 weeks

Non-Hormonal Options

For women who cannot or prefer not to use estrogen:

DHEA suppository (Intrarosa/prasterone):

• Converted to estrogen and testosterone locally in vaginal tissue
• Effective for dryness and painful sex
• Minimal systemic absorption

Ospemifene (Osphena):

• Oral SERM (selective estrogen receptor modulator)
• Acts like estrogen in vaginal tissue
• Prescription medication
• Effective but less so than vaginal estrogen

CO2 laser or radiofrequency treatments:

• MonaLisa Touch, FemTouch, ThermiVa
• Stimulates collagen production in vaginal tissue
• Requires multiple sessions, expensive
• Evidence mixed; not covered by insurance
• May help some women but less effective than estrogen

Lifestyle and Sexual Health

"Use it or lose it": Regular sexual activity (partnered or solo) maintains:

• Blood flow to vaginal tissue
• Tissue elasticity and tone
• Natural lubrication response

Pelvic floor physical therapy:

• Helps if vaginal tightness or pain is present
• Addresses pelvic floor tension (vaginismus)
• Teaches relaxation techniques

Foreplay and arousal:

• More time for arousal = more natural lubrication
• Focus on non-penetrative pleasure
• Use external stimulation (clitoral) to increase arousal

Communication with partner:

• Explain what's happening physically
• Request more foreplay, gentler touch
• Explore non-penetrative sex
• Use lubricant generously without shame

Timing and Progression

Vaginal dryness typically:

• Begins in late Wild Tide or Henapause (as estrogen drops)
• Worsens in early Pause and beyond (without treatment)
• Is progressive: Unlike hot flashes, it does NOT improve on its own
• Requires treatment: The tissue will not regenerate without intervention

Key point: Vaginal atrophy worsens over time if untreated. The longer you wait, the more tissue changes occur, and the harder it can be to restore comfort.

Myths and Misconceptions

Myth: "It's just part of aging; nothing can be done." Truth: Vaginal atrophy is highly treatable with estrogen, DHEA, or other therapies.

Myth: "I shouldn't use estrogen if I have a history of breast cancer." Truth: Vaginal estrogen is often safe even for breast cancer survivors (discuss with oncologist). The systemic absorption is minimal.

Myth: "If I don't have sex, I don't need to treat it." Truth: Vaginal atrophy causes discomfort even without sex—itching, burning, irritation, urinary symptoms. It's worth treating for quality of life.

Myth: "Lubricant is enough." Truth: Lubricant helps during sex but doesn't restore tissue health. Moisturizers and especially estrogen are needed for true healing.

Myth: "It's too late to treat if I've had symptoms for years." Truth: Vaginal estrogen can improve tissue health even years post-menopause, though it may take longer to see full benefits.

The Silence and Shame

Vaginal dryness is one of the least discussed menopausal symptoms, yet one of the most impactful:

• Women suffer in silence: Too embarrassed to tell partners or clinicians
• Clinicians don't always ask: Many doctors skip this question
• Partners don't understand: May interpret avoidance of sex as rejection
• Cultural shame: Women are supposed to be sexually available, not "broken"

Breaking the silence:

• This is a medical condition, not a personal failure
• It is common (50-70% of postmenopausal women)
• It is treatable
• You deserve comfort and pleasure

When to Seek Treatment

You don't have to wait until symptoms are severe. Seek treatment if:

• Sex is painful or uncomfortable
• You're avoiding intimacy due to dryness
• You have constant vaginal irritation or itching
• You're getting frequent UTIs
• You have urinary symptoms (urgency, burning)

Early treatment is easier and more effective than waiting years.

Long-Term Perspective

Vaginal atrophy is a chronic condition that requires ongoing management:

• If you use vaginal estrogen and stop, symptoms will return
• Treatment is long-term (potentially lifelong)
• But it's easy, safe, and effective for most women
• Quality of life improvement is profound

Many women say vaginal estrogen was life-changing—restoring sexual comfort, confidence, and intimacy.