What Actually Happens During Menopause?
Ladies, we need to talk about vaginal and vulvar health.
Especially as we age and go through perimenopause and menopause.
I know this topic may evoke a wide range of feelings.
This isn’t an area of the body we readily talk about most of the time.
And it can be connected to trauma and pain just as much as it can be connected to birth, pleasure, or connection.
So, if this isn’t the right time for this discussion, set it aside or reach out to a trusted person for support.
This topic is also challenging because it isn’t easy to initiate the conversation.
As a Sacramento based online telehealth naturopathic doctor, I know how complex this topic can be.
Sometimes, you might be concerned about symptoms but you think they’re too mild to bother bringing up.
Sometimes, you might not know any different so you assume your symptoms are normal.
Either way, you might feel like there’s no point in starting what can feel like a potentially awkward conversation.
And most doctors aren’t going to screen, ask or assess vaginal health aside from normal PAP or cervical cancer screening.
In fact, a 2013 survey at Johns Hopkins found that fewer than one in five OB-GYN residents get formal training in menopause medicine.
Which puts us in a bit of a pickle.
It’s estimated there’s about 50 million menopausal women in the U.S and if gynecologists aren’t getting enough training…
All this means that women don’t know what to expect when it comes to this area of health, and there’s a gap in care.
Not an ideal combo.
And in the meantime, we might be silently normalizing vaginal dryness, pain, or urine leakage without knowing what’s normal, what isn’t and what can be done.
This is what I mean when I say women’s health is feminism in action.
By openly discussing our menopause experiences, we’re empowering ourselves to take charge of our health.
And it’s why we talk about women’s health on this blog so much.
In the past, we’ve talked about using nutrition to alleviate PMS, whether there’s a reliable way to test for PMS, how PCOS relates to diet as well as depression, and even how to avoid hazardous chemicals in your makeup.
But we haven’t given menopause the attention it deserves.
So, let’s be the change we wish to see and talk about the genitourinary syndrome of menopause.
I promise this is going to help you – and your lady parts - feel better!
First, Let’s Talk About Anatomy
We’re talking about a few different body parts here.
Mainly, I’ll use vulvovaginal to describe the outer vulva and vaginal canal.
Both can be affected, but vulva is outside and includes the labia.
Vagina refers, more specifically, to the vaginal canal.
Other guests at this party are the bladder and urethra.
The bladder being where we hold urine and the urethra is the tube that exits the body.
What is The Genitourinary Syndrome of Menopause?
First, let’s call it GSM for short because it’s a mouthful.
Also known as atrophic vaginitis, GSM refers to the range of changes that happen to the vulva, vagina, bladder and urethra caused by declining levels of estrogen as you approach and pass menopause.
Estrogen makes things feel well toned and moisturized.
But as we age, estrogen will decline and we lose its “plumping” effect.
This, in turn, leads to a variety of symptoms which can include:
Vaginal dryness, irritation, burning or itching
Vaginal or pelvic pain or pressure
Dyspareunia (pain during sex)
Reduced lubrication
Loss of libido or difficulty achieving orgasm
Pain with urination
Urgency with urination
Urinary incontinence
Recurrent urinary tract infections
Urethral prolapse
Depression
RELATED: Naturopathic Depression Treatments And Support
How Common Is GSM?
Short answer? Very!
But, let’s give it a little more detail.
As estrogen declines, about 15% of premenopausal women can experience some of the symptoms listed above.
In older women who are postmenopausal, it’s estimated that 50-70% are symptomatic to some degree.
And what makes this particular set up symptoms challenging is that they’re progressive.
So, as more time passes without the effects of estrogen, symptoms will get worse.
I don’t say that to be harsh.
Rather, to emphasize that early detection and knowing what symptoms are attributed to these hormonal changes is super important.
Now, let’s be honest.
It feels like most of these conversations happen in hushed voices and allude to “the change.”
But no one says what to expect or what will change - aside from not getting a period.
In fact, according to this 2015 study, only 4% of women were able to connect their symptoms to GSM.
How To Tell If You Have GSM?
One telltale sign is vaginal dryness.
In fact, some studies estimate that the percentage of women who experience vaginal dryness is as high as 93%.
For some, this may also lead to irritation, burning or itching.
Also, this dryness and irritation can affect intimacy.
That can lead to painful intercourse, or bleeding or spotting during or after.
From a urinary perspective, recurrent urinary tract infections, urgency, stinging with peeing, and incontinence are also common symptoms.
In practice, I find urinary incontinence to be very common and often under the category of a fact of “getting older.”
But it doesn’t have to be that way.
As you’ll see as we transition into available therapies, there’s actually a lot that can be done.
First Line Therapy For GSM
The first line approach to GSM is to provide moisture and lubrication to the vulvovaginal tissue through lubricants and moisturizers.
A lubricant can be water, silicone or oil based and is used to relieve pain during sex.
Not to get too technical, but the thing you want to keep an eye out for is osmolality.
Mostly because a hyper osmotic lubricant will draw water out.
We want to promote water staying in cells instead.
Products will usually list the osmolality and you want to stay in the 300-400 range.
The lubricants at Good Clean Love fit the bill, for example.
In contrast, a vaginal moisturizer is meant to be applied regularly.
Its job is to mimic normal vaginal secretions and help lower your vaginal pH.
Lowering pH is a good thing and will help prevent infections, for example.
The ingredient to look for in a moisturizer is hyaluronic acid.
Yup, the same stuff you see advertised in face cream.
Hyaluronic acid helps bind and retain water which leads to the moisturizing effect.
A couple of examples include:
In general, a lubricant and or moisturizer is a good choice for mild or moderate symptoms.
In more severe cases, the first line therapies will likely need to be paired with the gold standard treatment: vaginal estrogen.
Low Dose Vaginal Estrogen – The Gold Standard
We come full circle since the reason all of these symptoms are happening is due to an estrogen deficiency.
Therefore, applying estrogen topically to the vaginal tissue is an effective treatment.
The North American Menopause Society (NAMS) released a statement on hormone therapy in 2022. They said vaginal estrogen is an effective treatment for GSM, and that there is no significant difference in effectiveness or safety across preparations.
In other words, whether the vaginal estrogen is a cream, tablet or ring doesn’t seem to matter much on how well it performs.
NAMS does encourage you to talk with your oncologist first though, if you have a history of breast cancer.
This is because there is a small potential risk of increasing circulating estrogen.
Although a 3.5 year long observational trial of breast cancer survivors on tamoxifen or aromatase therapy on low dose vagina estrogen saw no increased risk of breast cancer.
However, more studies are needed.
The most encouraging piece around vaginal estrogen is that in addition to being very effective at reducing symptoms, it can also slow progression.
And not only does the vaginal estrogen improve vulvovaginal symptoms, but it can also improve incontinence as well as recurrent UTIs.
For the latter, this means avoiding unnecessary rounds of antibiotics, which is a great win for your gut and your mental health.
Pelvic Floor Physical Therapy
Before we close, I also want to mention the potential importance of an expanded care team.
Especially the role of pelvic floor physical therapy as an adjunct to lubricants, moisturizers and estrogen therapy.
A 2019 study found that twelve weeks of one hour sessions focused on pelvic floor muscle training reduced GSM symptoms.
This had a positive and significant impact on quality of life and sexual function.
Some of the same researchers in 2020 found that training your pelvic floor improves circulation and the pelvic muscles’ ability to contract and relax.
This then has benefits on GSM and urinary incontinence.
All to say, that asking or urging your care team for a pelvic PT referral may be an additional option for you.
Book Your Appointment With Wild Lemon Health Today
If you’re struggling with any of the symptoms we talked about, I hope I’ve inspired you to know there are answers.
A good assessment, evidence based treatments and proper referrals can have such a significant impact on your life.
I believe that women of all ages need really good comprehensive care and the answers they may not be getting in a quick 7 minute visit.
If you want to make a plan to live healthy for the decades ahead, then book a FREE introductory call to learn more about the practice and our approach to women’s health during (and after) menopause.
