Less estrogen may cause the tissues of the vulva and the lining of the vagina to become thinner, drier, and less elastic or flexible.
Shifting levels of hormones—especially estrogen—during the menopause transition produce changes in a woman’s body. Both the vagina and the external female genitals (vulva) are affected.
Vulvovaginal atrophy. During perimenopause, less estrogen may cause the tissues of the vulva and the lining of the vagina to become thinner, drier, and less elastic or flexible—a condition known as "vulvovaginal atrophy" (see figure). Vaginal secretions are reduced, resulting in decreased lubrication. Reduced levels of estrogen also result in an increase in vaginal pH, which makes the vagina less acidic, just as it was before puberty.
| Vaginal lining with estrogen | Vaginal lining in low-estrogen state |
Illustration by Juliet Sweany
Lining of the vagina before menopause (left) and after menopause (right). Before menopause, when the vagina is well supplied with estrogen, its lining is thicker and has more folds, allowing it to stretch with intercourse and childbirth. After menopause, when levels of estrogen are low, the vaginal lining is thinner and has fewer folds, which makes it less flexible.
Dry, fragile vulvovaginal tissues are susceptible to injury, tearing, and bleeding during intercourse.
When a woman doesn’t have intercourse or other vaginal sexual activity on a regular basis following menopause, her vagina may also become shorter and narrower. Then, when she does try to have intercourse, she is likely to experience pain, even if she uses a lubricant. That’s because dry, fragile vulvovaginal tissues are susceptible to injury, tearing, and bleeding during intercourse or any penetration of the vagina. The resulting discomfort can be so great that the woman avoids intercourse and the condition worsens. Sometimes, even women who are not sexually active are bothered by vaginal dryness and the irritation that may accompany it.
Continuing to have regular vaginal sexual activity through menopause helps keep the vaginal tissues thick and moist and maintains the vagina’s length and width. This helps keep sexual activity pleasurable.
Atrophic vaginitis. When “–itis” is added to a word, it generally means inflammation. Inflammation of the vagina after menopause in a woman who is not using hormone therapy is called "atrophic vaginitis." This condition can include redness of the vagina and vaginal discharge. It’s associated with the loss of estrogen after menopause and usually improves with the use of low doses of vaginal estrogen therapy, as discussed later.
These menopause-related vulvovaginal symptoms may occur early in the menopause transition or not until after several years of reduced estrogen levels. What’s more, not all women develop troublesome vulvovaginal symptoms around menopause. But those women who do experience vulvovaginal symptoms (dryness, irritation, burning, itchiness, pain) should not automatically assume that reduced estrogen levels are the reason for these symptoms, as there are other possible causes.