Vaginal dryness in menopause: the symptom that does not pass

Why the name changed

What used to be called vaginal atrophy was renamed genitourinary syndrome of menopause, and the new name is more useful because it describes the actual extent of the problem. Estrogen receptors are dense throughout the vulva, vagina, urethra and bladder base, so falling estrogen affects all of them together.

That is why dryness so often arrives alongside urinary urgency, discomfort passing urine, and recurrent urinary tract infections. Treating them as separate problems, in separate appointments, with separate clinicians, is common and unnecessary.

The part that makes it different

Hot flashes end. Sleep usually improves. Mood usually stabilises. This one does not follow that pattern — without treatment it tends to worsen progressively, because it reflects an ongoing tissue change rather than an adjustment to shifting hormone levels.

Estimates of how many postmenopausal women are affected commonly fall between a third and half, and the proportion rises with years since menopause. The proportion who receive treatment is far smaller.

The practical consequence: waiting it out is the one strategy that reliably does not work here.

What it actually presents as

Dryness is only the headline. The fuller picture:

• Discomfort, burning or itching in the vulval area, not only during sex
• Pain during sex, sometimes with light bleeding afterwards
• Urinary urgency and needing to pass urine more often
• Discomfort or stinging when passing urine with no infection found
• Recurrent urinary tract infections
• Loss of elasticity, making examinations and smear tests painful

Why local estrogen is treated differently from systemic

This is the point most worth understanding, because fear of hormone therapy stops a large number of women accepting a treatment whose risk profile is not the same thing.

Local vaginal estrogen — pessaries, creams, rings — delivers a low dose to the tissue itself. Systemic absorption is minimal, and it is generally not considered to carry the risks associated with systemic hormone therapy. Guidance supports its use for a considerably broader group, including long-term use and, after specialist discussion, in many women with a history of breast cancer.

Unlike systemic hormone therapy given for hot flashes, the treatment here needs to continue for the benefit to continue, because the underlying tissue change resumes when it stops.

Vaginal moisturisers used regularly, and lubricants used during sex, are genuinely useful and are not in competition with local estrogen. Non-hormonal prescription options also exist.

When to see someone

Raise it at any appointment, and raise it directly, because you are unlikely to be asked. Clinicians frequently do not ask and patients frequently do not volunteer, which is the main reason a highly treatable condition goes untreated for years.

Get assessed promptly rather than assuming dryness for any bleeding after the menopause, any lump or persistent skin change on the vulva, or discomfort with a discharge, since these need a different examination.