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Changes to the vagina and vulva in perimenopause and menopause, what to expect.


Changes that may occur to the vagina and vulva in perimenopause and menopause.



There are changes that can occur to the vulva and vaginal tissues that may begin in perimenopause and continue through menopause that are not widely discussed and understood. This can be an awful shock to many women who are totally unaware of what can occur and may affect a woman’s quality of life from a physical perspective as well as emotionally and mentally.


As hormones begin to decline in peri-menopause changes to the vagina begin and one of the first signs of this occurring is often lack of lubrication during intercourse.

The previous terminology for vaginal and vulval changes due to menopause was Vulvo-Vaginal Atrophy (VVA) and the newer term is the Genitourinary Syndrome of Menopause (GSM) which I think is a better name than name than vaginal atrophy!! I had never heard of it, even when I was studying naturopathy, we were not taught about this. It shows such a lack of representation, education, and support for women in mid-life or even for women who go into early menopause due to the removal of ovaries, premature ovarian failure, chemotherapy, radiotherapy or for other reasons.


Thankfully, not every woman experiences the same levels of discomfort and changes and some do not notice much difference at all. This article is to bring to your awareness to what could occur and in future articles how you can support yourself.

As hormones begin to decline in perimenopause changes to the vagina begin and one of the first signs of this occurring is often lack of lubrication during intercourse.


Perimenopause


Perimenopause is the time that leads up to menopause. This is when hormone production decreases and you may begin to experience symptoms.


It can begin from the late thirties but for many women it is around 45 years of age.

Perimenopause can last for about 4 years to a decade or more! Some women may only experience a few months of it, but this is not common.

Menopause


You are in menopause when you have not had a period for 12 consecutive months, so it is the 12-month anniversary from your last period that you are considered to be in menopause.


The average age of menopause is 51 years although it can occur earlier or later.


Post-menopause


You are post-menopausal the day after your 12-month anniversary of your last period.


Changes to the vagina, vulva & sexual function


When hormones decrease, particularly oestrogen, there are a series of things that may happen:


  • Vaginal tissue lining (epithelium) thins

  • Vaginal dryness and discomfort, causing painful intercourse

  • Small tears and cuts like paper cuts due to fragile tissue around the vaginal opening (vestibule) through to the anus and clitoris which can be excruciatingly painful

  • Poor lubrication

  • 75% of women have discomfort that affects their sex life although it is most likely more as many women do not discuss the situation with their doctor or health care professional

  • Vaginitis (inflammation of the vagina that can result in discharge, itching and pain) can occur due to a change in the balance of vaginal bacteria often caused by reduced oestrogen levels.

  • Bacterial vaginitis

  • Loss of sex drive

  • Pubic hair decreases

  • Shrinking and flattening of the vulva – labia majora and minora

  • Shrinking of the clitoris and loss of clitoral sensation

  • The vagina internally can shrink to pre-pubertal size and the lining of the uterus atrophies (shrinks)

  • The muscular vaginal layers can be replaced by fibrous tissue resulting in loss of elasticity

  • With the above changes (thinning vaginal epithelium, dryness, and loss of elasticity) is what causes painful intercourse, mechanical injury and post intercourse bleeding can occur

  • Loss of sexual sensation and pleasure, burning, itchiness

  • Thin, watery, yellow, or grey discharge

  • Pale, shiny, dry, and thinning labia, if inflamed there may be redness or paleness with red spots.

  • Urinary tract infections can be common

  • Reduction or lack of vaginal mucous

Vaginal pH


Due to reduced oestrogen, the cells of the epithelium (lining) of the vagina aren’t constantly making new cells (the cells make food – glycogen - for lactobacilli ) so if there isn’t any food for the lactobacilli to grow they reduce in numbers. The lactobacilli keep the environment acidic and this prevents other organisms colonising the vagina that can cause urinary tract infections, vaginal infections, and inflammation.


You can do a test at home to determine your vaginal pH (the acidity or alkalinity of the environment). In pre-menopausal years, a normal vaginal pH is between 3.8 and 4.5 (moderately acidic). If you are in peri or post-menopause a pH of 4.6 or more (less acidic) can indicate that you have vulvo-vaginal atrophy and may be prone to urinary tract and other infections. You can purchase vaginal pH test strips online.


It has been suggested that testing the pH of the vagina can be a good alternative test to confirm menopause.


In my next article I will be talking about treatments and support for vaginal atrophy.



 


References


Brown KH, Hammond CB. Urogenital atrophy. Obstet Gynecol Clin North Am. 1987;14(1):13-32.


Farrell Am E. Genitourinary syndrome of menopause. Aust Fam Physician. 2017;46(7):481-484.


Mitchell ES, Woods NF, Mariella A. Three stages of the menopausal transition from the Seattle Midlife Women's Health Study: toward a more precise definition. Menopause. 2000;7(5):334-349. doi:10.1097/00042192-200007050-00008


Moradan S, Ghorbani R, Nasiri Z. Can vaginal pH predict menopause?. Saudi Med J. 2010;31(3):253-256.

Patni R. Genitourinary Syndrome of Menopause. J Midlife Health. 2019;10(3):111-113. doi:10.4103/jmh.JMH_125_19

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