Vaginal atrophy is a physiological condition that affects 100 per cent of women after menopause but 90 per cent of those women won’t have heard of it. They also don’t realise the devastating impact it could have on their sex lives if left untreated.
That's according to Dr Rita Galimberti, specialist in gynaecology and medical director of Femplus Clinic in Dublin, who is talking about the deterioration in the vagina after menopause and specifically one of the worst side effects of it, vaginal dryness.
A recent survey, carried out on behalf of Regelle vaginal moisturisers, found that out of 500 Irish women surveyed, 70 per cent of those experienced vaginal dryness while 41 per cent experienced painful sex. Some 45 per cent said they avoid sex altogether due to the condition.
“The condition will not affect every woman. For example, if women are sexually active and are enjoying a good sexual relationship, then it is a problem but if they are not then it probably won’t. Unfortunately, it’s a problem we see quite late in women as there is a lot of ignorance around this.”
Galimberti says she is passionate about this subject as so few women are aware of the physiological change that occurs in the vagina after menopause but more so the fact that the deterioration can be stalled or stopped in its tracks completely if women take action at the right time.
She says that when she sees menopausal or perimenopausal (the phase that takes place just before the cessation of periods) women in her clinic, she explains to them that atrophy will occur in the vagina and offers advice on the correct course of action.
Dr Galimberti says a lot of women self-diagnose and seek over-the-counter medication for what they believe to be thrush, with symptoms of that condition presenting similarly to vaginal dryness.
“Women go on with the problem for a long time before they get properly treated,” she says.
Dr Louise Newson, a leading menopause expert in the UK, says that while menopause is usually the primary cause of vaginal dryness, things like oral contraceptives, breastfeeding, low libido or irritation from hygiene products can also cause it. A change in hormone levels after chemotherapy often induces menopause, leading to vaginal dryness also.
“It’s one of the most common problems that I see in my practice and the symptoms can be horrific, but very few women talk about it,” she says.
She explains how atrophy occurs: “Within the lining of the vagina, the cells become thinner and there is less collagen in there so it becomes less elastic and there is also less blood supply so it basically dries out. It mostly causes a lot of irritation, soreness and pain during intercourse but there may even be discomfort with everyday things like walking, sitting down and exercising.”
Illnesses like diabetes and arthritis, and many medications including antihistamines can also cause dryness but Newson says it can occur for no reason at all.
Dr Sharon Moss, consultant gynaecologist in the Beacon Clinic in Dublin, explains that dryness can manifest itself in other ways: “One of the most common problems is bladder or urinary symptoms – often recurrent cystitis (especially after intercourse) or recurrent urinary tract infections (bladder infections). It might just be feeling a need to void more frequently, or getting up more during the night.
“There’s also a higher incidence of thrush and other vaginal infections like BV (bacterial vaginosis).
“Women who are well past menopause and have had low oestrogen levels for many years can suffer terribly with such symptoms. Sometimes, in severe cases, it can be sore just to sit down and there can be constant stinging and irritation.
“They are also more likely to develop pelvic floor dysfunction, whereby the pelvic muscles go into spasm because of ongoing irritation,” she says.
Dr Newson says that women often describe the pain during intercourse like getting lots of paper cuts in the vagina, while another very distressed woman described it to her like “having a red hot poker” inside her.
So why are women suffering in silence? Dr Galimberti says they are not being educated properly about the condition and about menopause in general. By the time most women seek her help, the atrophy is at an advanced stage, something she finds frustrating as the condition need not have progressed at all.
Dr Moss thinks there is an embarrassment factor for most women. “I think it’s not discussed much because women generally don’t talk about their vaginas. Women are more comfortable opening up about menopausal symptoms nowadays, but to talk about vaginal health is probably still a step too far for many. I always ask my patients directly, even if they’re only in their 40s, because being proactive is much better than waiting until there is ongoing burning and pain.”
Often the women she sees have no confidence because they feel they can’t be intimate with their partners. “It can be absolutely horrific, and women can feel very isolated. Again, no one talks about it and most women in this situation feel they’re the only ones to experience it.”
There are various ways to manage the dryness, including avoiding irritants such as soaps and perfumes and always washing with plain water. Allow the vagina to “breathe” by not wearing underwear at night, and wearing cotton underwear during the day. Lubricants should be used for intercourse but not the usual suspects – as “most lubricants available at the pharmacies have additives. Lubricants such as Yes, Sylk and KY Pure have no additives and are better to use,” Moss says.
All the doctors agree that several treatments can be very beneficial. “Vagifem is an oestrogen pessary that improves vaginal skin health over months, and it’s the usual first line of treatment. However, it has to be prescribed and it isn’t suitable for women who need to avoid oestrogen – for example, women with a history of breast cancer. Vaginal moisturisers such as Regelle can also work quite well to improve the vaginal environment,” she says.
Dr Galimberti agrees that both vaginal gels and vaginal HRT are effective.
“There were concerns in the past that vaginal HRT could affect the lining of the endometrium but we don’t have high oestrogen preparations anymore and we keep an eye on the lining of the uterus for any changes while women are on it.” For this reason she often prescribes vaginal HRT long-term for many women. She says women who are given an individualised consultation and are at low risk of cancer can potentially stay on vaginal HRT for 10 to 20 years. “Once you stop using it the vagina will go back to the way it was, so you need to stay on it.
“I do believe it affects relationship if you no longer want to have sex because of this. Women should know it’s common and it’s treatable,” she says.
: It started when the menopause was about two to three years in, I really began to notice it then. The vagina stopped responding to stimulus during sex. I had always enjoyed sex throughout my life so to lose that part of me was really upsetting. I wasn’t prepared to lose it. It became very painful having sex and then you get tense which has a snowball effect. You could tear and it almost felt like I was recovering from an episiotomy (tear). Then it became impossible. I spoke to my partner about it and tried to work around it but you really don’t feel like having sex.
I went to my GP and was referred to a gynaecologist who suggested I go on vaginal HRT which is a very small oestrogen suppository that is inserted into the vagina. It works to lengthen and moisten the area. I was a little bit concerned by the fact that it is HRT and I was worried about some of that getting into my system but the doctor assured me that little or none enters the body.
I split up with my long -term partner soon after, but am now in another relationship and the vaginal HRT really worked for me. Initially, I used it every day, for a fortnight, and then I used it twice a week for six months. My gynaecologist said I could come on and off it as needed.
It has definitely improved my life, and I have no fear of pain during sex now.
Tanya's story: I was going through the menopause and just started to feel dry. You don't feel like a woman when you're dry down there. I had my womb removed and went through menopause at age 48. I had polyps in my womb and I was haemorrhaging so it was a difficult time anyway. I went on HRT, and the world is your oyster when you're on it and you feel great. I had no pains, aches or dryness but my GP only allowed me stay on that for five years. When I came off it everything started breaking down again. You don't feel good in yourself and are more tired. You feel yourself getting old before your time. I just put up with it and tried to get on with life. It put me off having sex as it would hurt me. It was painful. It is like a burning pain, like a Chinese burn on your arm. I never told my partner and he never realised. You would put sex off as long as you could. I felt sad and not like a woman but people say to me, I don't look in my late 50s. I would use Vaseline or oil as lubricant but now I use gels so I'm not as nervous having sex now. I also use it during the week just to feel good in myself.