The arrival of new, uncomfortable and unexpected vaginal symptoms around the time of the menopause can feel like the last straw when a patient might already be struggling to deal with a myriad of physical, mental and emotional changes at the same time.
On average, some people will begin to notice certain physical or vasomotor symptoms from the age of 45 and upwards, but some can develop more subtle symptoms before this, not always associating it with the menopause. (Peycheva 2022) Some symptoms can initially appear out of the blue and then disappear before returning later.
Period irregularity, new aches and pains, changes to mood, dwindling libido and reduced cognitive ability are common complaints at this time with varying degrees of severity and impact on daily life (BMS August, 2023).
Fluctuating and declining levels of oestrogen during the perimenopause can leave some people unable to fulfil usual work duties on some days, feeling low, lacking in confidence or motivation and exhausted and exasperated by day flushes and night sweats from one week to the next.
A cycle of ever changing symptoms can continue until the average age of 51 in the UK, or even later, meaning that for many - almost a decade of their life can be impacted on with far reaching effects on overall well being, relationships and employment.
The additional development of new and what might feel like frequent vaginal infections, vulval irritation and/or urinary infections can cause some initial confusion as to the potential underlying cause.
Vaginal symptoms around this time are thought to affect up to 80% of people, but the subject is largely under recognised and often under treated (BMS 2022).
Many women initially self treat with a variety of over the counter treatments including thrush creams and pessaries or urine neutralising powders believing these will solve the problem.
However, without appropriate assessment and diagnosis, an initial symptom such as vaginal dryness around the time of the menopause can lead to the development of a combination of additional symptoms including soreness, redness, burning/stinging, skin tearing, urinary urgency/frequency, pain when sitting, painful sex and vulvo-vaginal itching (Palma 2017).
Without assessment and treatment these symptoms can evolve, increase and worsen over time.
Terminology
A combination of vaginal, vulval and / or urinary symptoms comes under the umbrella term – GSM (genitourinary syndrome of the menopause) but is historically termed vaginal atrophy (VA), and more recently Urogenital Atrophy. For the purposes of this article, the all encompassing term GSM will be utilised.
As we move through the perimenopausal phase, the ovaries produce less oestrogen and testosterone which until this point have had a beneficial effect on the vagina, vulva, the clitoris and overall skin health of the intimate areas, as well as assisting with arousal and desire. Without consistent levels of oestrogen, women can begin to feel the effects within the vagina itself, externally across the vulva and in the bladder.
A loss of elasticity in the vaginal canal itself, less oestrogen within the vulvo-vaginal epithelial tissue and around urethral structures can all create new challenges - in physical as well as in emotional and practical terms.
Fluctuating and erratic production of oestrogen means that less lubrication is produced before and during sex, the vaginal canal begins to shorten and may not stretch freely during sex itself. A combination of these factors alone can make sex painful and may even cause some women to avoid sex altogether for fear of the discomfort which can occur during and afterwards.
However, a woman does not need to be sexually active to develop vaginal symptoms at this time, and rather than talking about the changes or asking for help, they might feel that this is imply just part of the ageing process. Some have even called this a ‘silent epidemic’ (Briggs, 2022).
Without treatment, and ideally a combination of treatments, symptoms are likely to become chronic and progressive and may affect day to day tasks which are normally enjoyed (Palacios, 2019).
Treatment options
Vaginal oestrogen is a viable treatment option to many and helps restore oestrogen directly back into the vagina and surrounding tissues. Not only can this help to relieve vaginal discomfort, but it can also tackle urinary symptoms by penetrating through the vaginal walls and into the urethra.
It comes in a range of treatment products including vaginal tablets, creams, gel, pessaries and a vaginal ring. Use of vaginal oestrogen can be lifelong, as symptoms are likely to return if treatment is stopped. It is also possible to use vaginal oestrogen alongside HRT. (NICE, 2023)
Most vaginal oestrogen is taken via an initial loading dose period which can be for around 2-3 weeks where treatments are inserted or applied daily during this time before dropping use down to maintain vaginal health around twice weekly. For persistent or hard to manage GSM, using vaginal oestrogen more often is possible with menopause specialist oversight (BMS, 2023).
For some individuals vaginal oestrogen alone may not always be sufficient enough to improve symptoms. A combination of vaginal oestrogen used alongside a non hormonal vaginal moisturiser and lubricant when required, may be a more optimal and holistic choice, with additional consideration towards a change of intimate area cleansing products which can help provide longer lasting comfort and relief. A degree of trial and error with different treatments is not unusual until the user finds products which do not worsen symptoms or cause any new irritation. Caution is advised with ingredients within moisturisers and lubricants which are commonly known vaginal irritants including glycol, glycerin, soy, parabens, chlorhexidine, petroleum oils and essential oils.
Non hormonal moisturisers can help to lock in and maintain moisture in the vaginal epithelium helping to gradually release moisture over a few days and keeping tissues moist and healthy. They can help the natural pH of the vagina to stay around 4.4. Lubricants help to coat the vaginal walls during sex, preventing friction and subsequent trauma as a result. Some people report micro fissures after sex which take time to heal and become even more painful when passing urine. Caution is advised when using an oil based lubricant with condoms.
An example of an optimised treatment combination could be the use of Estradiol pessaries such as Vagifem/Vagirux, inserted twice weekly alongside a vaginal moisturiser such as Yes VM which can be inserted by an applicator into the vagina at bedtime for 2-3 nights of the week when Estradiol is not being used. Some may feel they have to insert moisturiser more often initially depending on the severity of the as yet untreated GSM.
‘Yes’ products rate highly by the WHO in terms of osmolality values(how much is absorbed of the product into the vaginal tissues) and their ability to help maintain normal vaginal pH levels.
Edwards and Panay (2016) discussed the importance of product osmolality and pH balance when choosing a vaginal moisturiser or lubricant.
Additionally, consider washing the intimate areas with an emollient such as Epaderm Ointment, Hydromol or Zeroderm. These can also be applied lightly after washing and gently patting the skin dry to help soothe irritated vulva skin.
Some people may feel that while pessaries/gels inserted vaginally help them with any internal discomfort or dryness, they still struggle with vulva discomfort or soreness/redness at the vaginal entrance and may find that using a vaginal oestrogen cream such as estriol 0.1% applied sparingly externally, helps provide better all round relief of symptoms vaginally as well as externally. This is off licence use of the product, but commonly recommended.
Table 1. Typical vaginal oestrogen treatments
| Product Name | Drug | Formulation |
|---|---|---|
| Vagifem/Vagirux | Estradiol | Vaginal Tablets - Available in pre loaded / self loaded applicators. |
| Ovestin | Estriol | Cream |
| Estriol 0.01% | Estriol | Cream |
| Blissel | Estriol | Gel |
| Imvaggis | Estriol | Pessary |
| Estring | Estradiol | Silicone ring |
| Intrarosa | Prasterone | Pessary |
| Gina | Estradiol | Vaginal tablets |
Table 2. pH and Osmolality values for commonly used vaginal moisturisers and lubricants
| Products available on NHS Prescription | |||
|---|---|---|---|
| Name | Ingredients | pH | Osmolality mOsm/kg |
| Gynomunal Vaginal Moisturising Gel | Hop extract (Humulus lupulus), Tocopherol acetate (Vitamin E), Purified water, Propylene Glycol, Denatured Ethanol, Soya Lecithin (E322), Carbomer, Methyl-4-hydroxybenzoate (E219), Cholesterol, Imidazolidinylurea, Triethanolamine, Sodium Edetate, Hyaluron | 5.84 | >2000 |
| Hyalofemme Vaginal Hydrating Gel | Hydeal-D (Hyaluronic Acid Derivative), Propylene Glycol, Carbomer, Methyl p-Hydroxybenzoate, Propyl p-Hydroxybenzoate, Sodium Hydroxide, Purified water | 4.88 | 1729 |
| Regelle Long lasting Vaginal Moisturiser | Purified water, Polycarbophil, glycerol, mineral oil, hydrogenated palm oil glycerides, carbopol 974P and sorbic acid. | 2.88 | 2012 |
| Replens MD Longer lasting Vaginal Moisturiser | Purified water Ph. Eur.78.64% w/w, Glycerin, Mineral Oil, Polycarbophil, Carbomer Homopolymer Type B, Hydrogenated Palm Oil Glyceride, Methylparaben, Sorbic Acid and Sodium Hydroxide | 2.95 | 2011 |
| Sylk Natural Intimate Lubricant | Water, Extracts of kiwifruit plant and citrus seed, Xanthan Gum, Vegetable Glycerin, Citric Acid, Potassium Sorbate, Sodium Citrate | 4.47 | 877 |
| YES VM Vaginal Moisturiser | Aqua, Flax Seed Extract*Aloe Barbadensis Leaf Juice*, Locust Bean Gum*, Guar Gum*, Sodium Chloride, Xanthan Gum, Potassium Sorbate Citric Acid, Phenoxyethanol | 4.15 | 250 |
| YES Water-based vaginal lubricant | Aqua, Aloe Barbadensis Leaf Juice*, Flax Seed Extract*, Guar Gum*, Locust Bean Gum*, Xanthan Gum, Sodium Chloride, Potassium Sorbate Citric Acid, Phenoxyethanol | 4.08 | 154 |
| OTC Products available from Pharmacies and online | |||
| Astroglide Gel Lubricant | Purified Water, Glycerin, Hydroxyethylcellulose, Chlorhexidine Gluconate, Methylparaben, Glucono Delta Lactone, Sodium Hydroxide | 4.38 | 6100** |
| Astroglide Ultra Gentle, Sensitive Skin. Lubricant | Purified water, Xylitol, Hydroxyethylcellulose, Aloe Barbadensis Leaf Juice, Pectin, Chamomilla Recutita (Matricaria) Flower Extract, Phenoxyethanol | 4.56 | 945 |
| Balance Activ Menopause, Vaginal Moisturising Lubricant | Phosphate Buffered Saline, Sodium Hyaluronate (Hyaluronic Acid) Phenoxyethanol, Methylparaben | 5.64 | 309 |
| Canesintima Intimate Moisturiser | Acqua, Glycerin, Glyceryl Polymethacrylate, Capryloyl Glycine, Sorbitol, Acrylates/C10-30 Alkyl Acrylate Crosspolymer, Sodium Hyaluronate, Sodium Benzoate, Sodium Hydroxide, Galactoarabinan, Butylene Glycol/Camellia Japonica Leaf/Flower Extract, Tetrasodium EDTA, p-ansic Acid, Levulinic Acid | 5.63 | 846 |
| Durex Play Feel Lubricant | Purified Water, Propylene Glycol, Hydroxyethylcellulose, Benzoic Acid, Sodium Hydroxide. | 5.48 | 1563 |
| KY Jelly Lubricant | Water, Glycerin, Hydroxyethylcellulose, Chlorhexidine Gluconate, Gluconolactone, Methylparaben, Sodium Hydroxide | 4.49 | 2007 |
| Pjur Med Natural Glide Personal Lubricant | Aqua, (water), Glycerin, Xanthan Gum, Benzyl Alcohol, Sodium Benzoate, Potassium Sorbate, Citric Acid | 4.41 | >2000 |
| Pjur Woman Nude Lubricant | Aqua (Water), Propylene Glycol, Ethoxydiglycol, Hydroxypropyl Guar Hydroxypropyltrimonium Chloride, Hydroxyethylcellulose, Sodium Saccharin, Citric Acid | 4.42 | <2000 |
| Sensilube Hydrating Intimate Gel | Aqua, Phenoxyethanol, Polyacrylamide, Hydroxyethylcellulose, Methylparaben, Ethylparaben, Propylparaben, Citric Acid | 5.99 | 16 |
pH values in red are outside the normal vaginal pH of 3.88-4.5. [1]
mOsm/kg values in red exceed the ideal osmolality threshold of 380 mOsm/kg recommended by the World Health Organization for a personal lubricant. [1]
[1] World Health Organization. Use and procurement of additional lubricants for male and female condoms: WHO/UNFPA/FHI360 advisory note 2012 [7 July 2015].
Available from: http://apps.who.int/iris/bitstream/10665/76580/1/WHO_RHR_12.33_eng.pdf
**Osmolality value taken from a review of recent studies on Personal Lubricant Safety by Lauren K Wolf PhD, in Chemical and Engineering News ISSN 0009-2347
All ingredients taken from packs purchased June – August 2015. Product and Batch numbers available from The Yes Yes Company Ltd.
Treatment combinations which encourage rotating between vaginal oestrogen and non hormonal treatments may provide more effective and longer lasting relief than using vaginal oestrogen alone.
Pelvic physiotherapy
A women's health physiotherapist can offer pelvic physiotherapy to help manage symptoms affecting the vagina including hypertonic / hypotonic pelvic floor and the symptoms this can cause including urinary leakage, urgency, dyspareunia or vaginismus. Hypertonicity can arise from trauma, muscular dysfunction such as sitting for long periods and conditions such as IBS, vulvodynia and endometriosis which cause pain and can lead to permanent or temporary contraction of the pelvic floor.
Those who cannot, or have been advised not to use vaginal oestrogen treatments such as anyone who is using an aromatase inhibitor for the treatment of breast cancer, may find a combination of non-hormonal products to be most useful. Non-hormonal choices are usually the first option for those with breast cancer with vaginal oestrogen only offered as an off-licence option for those who feel symptoms are severe.
Some, who are using aromatase inhibitors and who feel their vaginal symptoms are affecting their quality of life, can seek specialist oncology opinion on whether the use of a vaginal oestrogen could be a consideration for them. This may involve switching from an aromatase inhibitor to Tamoxifen to allow the vaginal oestrogen to work optimally in the vagina, or else using vaginal oestrogen in very low doses – but consideration of the individual and their risk factors should be taken into account and vaginal oestrogen may not always be advised.
It is worth considering how some treatments may have to be increased during times of what feels like a worsening of the usual GSM symptoms. Stress, sex, exercise, wearing tight fitting under garments and sitting for long periods of time are all known culprits for causing what is sometimes referred to as a ‘flare-up’.
During this period, which can in some cases last anything between a few days to 1-2 weeks at a time, consideration of how increasing how often non hormonal moisturiser is inserted or vaginal oestrogen cream/pessaries are applied/inserted – may help to reduce inflammation and discomfort and the duration of this episode, before then returning back to their normal maintenance dose.
Non-oestrogen based treatments
DHEA or dehydroepiandrosterone is a precursor to androgens which converts to oestrogen and testosterone. It is a hormone that is made naturally by the adrenal glands and the ovaries. In menopausal women, the majority of DHEA is produced by the adrenal glands. Prasterone comes in small waxy pessaries containing DHEA which are inserted into the vagina nightly. It is a treatment option normally reserved for those who have not found vaginal oestrogen to be effective enough and may need to be initiated by a menopause specialist, although some GPs are able to offer this themselves.
Ospemifene is a selective oestrogen receptor modulator (SERM) and is taken orally once a day. It works to reduce vaginal dryness and painful sex by lowering vaginal pH and improving cell maturation in the vaginal wall lining. It can be offered to those who have completed treatment for breast or endometrial cancer but as yet there have been no clinical trials for people currently undergoing treatment (BMS, 2023). It is, however, not without side effects which include hot flushes.
Laser treatment
A course of laser therapy to the vagina aims to stimulate collagen production and improve the mucous membrane improving vaginal dryness and dyspareunia. The procedure is expensive and usually only available either privately or as part of a clinical trial. NICE issued a statement in 2021 advising that further research is required into the long term use and efficacy of laser treatment to help GSM.
Conclusion
A combined treatment approach to help manage GSM is often more effective than the use of single treatments alone, and using the preferred combination as part of a regular maintenance regimen. Failure to do so can result in a return or worsening of existing symptoms. Knowing when to modify the use of prescribed vaginal oestrogen or initiate or alter the use or type of non hormonal treatments alongside this, may help to reduce the severity of vulvovaginal discomfort and limit the duration of symptomatic flare up.