As soon as I turned 40, along with longer and heavier periods, night sweats and migraines, I also started having itching, particularly in the transitional areas between haired to non-haired skin; it worsened right before my periods started and would go away other times but no other symptoms indicative of yeast or bacterial infection. The labia also seemed smaller and darker in retrospect.
I went to see one GYN and his response was basically– yeah, you’re getting older. We can try something to stop the periods (but no thoughts on the itching or migraine changes).
Later, it worsened to tearing/lacerations in the same area after the most minor things, including wiping after the bathroom, spreading things to rinse in the shower, and most recently, intimate activity with my partner. Even after using an IUD prescribed by a second gynecologist, though my tissues have plumped up, I still have tearing and shrunken genitalia. Most resources (including the wiki) mention that these things happen AFTER periods stop, but it seems like my body just decided to go full-bore as soon as my hormones started to change. I’m so sad/scared/angry about my body and the thought of having to deal with this for the rest of my life and that no one warned me that this could happen and so early.
(This is an excerpt from someone’s real-life experience. Courtesy: Reddit)
Genitourinary syndrome (aka vulvovaginal atrophy) is incredibly common among peri- and post-menopausal women. The most common symptoms include vaginal dryness, irritation or itching, and painful sex, with a prevalence of 13% to 87% among different populations. Yet, a majority of women suffer in silence due to the conditioning that such discomfort is part of aging and must be endured or due to the lack of awareness regarding treatment options. Therefore, these symptoms are under-reported, under-diagnosed and under-treated.
Not just that!
The need for fulfilling relationships and intimacy in midlife and beyond is dismissed or even shamed in community settings. Therefore, seeking treatment for vaginal atrophy is looked down upon despite debilitating symptoms, pushing women to self-medicate, which may not always be beneficial and safe. Beyond physical discomfort, these symptoms can deeply impact emotional well-being, self-confidence, relationships and quality of life (mood changes due to pain and irritation).
And then, there is fear of hormonal treatment. Many women and their families are apprehensive of hormonal options for fear of side effects. But here’s what you should know: Extensive research shows that low-dose vaginal hormone therapy is significantly safer than systemic hormone therapy—even for women with high-risk conditions like hormone-sensitive cancers. Read on to know more.
Why does the genitourinary syndrome of menopause (GSM) occur?
GSM is the manifestation of the pelvic changes that occur due to estrogen loss during peri- and post-menopausal phases. As tissues and neurons in pelvic organs like the urinary bladder, uterus, cervix, vagina, and external genitalia are estrogen-sensitive, the lack of circulating estrogen causes structural and functional changes, altering the entire pelvic environment.
Eventually, when the vaginal wall thins down with age or severe hormonal depletion, the estrogen receptors present on the surface decrease in number and activity, leading to both physical degeneration and reduction in estrogen sensitivity (as they are mutually dependent).
Healthy vaginal surface Thinning of the vaginal wall
Alterations in the vaginal mucosa i.e. flattening of the vaginal skin surface and loss of texture causes a decline in the beneficial vaginal bacteria that maintain an acidic pH to keep infections at bay in a healthy condition. Changes in the vaginal microbiome allow abnormal bacterial species to flourish, which can have long-term health implications on reproductive health. It can also lead to recurrent UTIs.
Collagen and elastin production is disrupted, affecting the integrity of connective tissues and smooth muscle contractility. The secretion of hyaluronic acid, a natural moisturizing agent in the vagina, also declines. The nerve distribution in the vagina is also directly impacted by estrogen levels.
What to expect?
The above-mentioned estrogen-dependent processes can result in a myriad of changes in the vulvovaginal area, including but not limited to:
Loss of fat in the external genitalia, causing shrinkage of the labia (vulval lips) and vulval opening
Reduction in vaginal wall thickness
Cracking of the vaginal surface
Loss of vaginal rugae (ridges)
Shortening/ narrowing of vagina due to stiffness
Loss of sensitivity in the vagina and clitoris
A combination of genital, urinary and sexual symptoms may occur simultaneously and their severity can vary with time, activity and hormonal changes. The non-specific nature of symptoms can be confusing and frustrating. For some women, vulvovaginal symptoms may start very early on in perimenopause even when their cycles are regular, while some others may experience them at later stages or never at all.
How is GSM diagnosed?
As many of these symptoms overlap with other medical conditions, diagnosis can be challenging. However, GSM is diagnosed based on a combination of urinary and vaginal symptoms, as well as by eliminating other possible conditions.
There is anecdotal evidence that women do not bring up genitourinary symptoms unless specifically asked. As the diagnosis is primarily based on self-reported symptoms, medical history and physical examination, open conversations with the care provider are critical. In specific cases or when symptoms persist after initial treatment, pH testing, vaginal smear (biopsy) or microbial culture tests may be prescribed.
How to prevent/ minimize the symptoms?
Avoid using cosmetic products on your genitalia, your vagina is a self-cleaning organ. Genitals and the skin around them can be (mostly will be) darker than the rest of your body due to friction and hormonal influence. It is best to make peace with this fact and not perceive it as a lack of cleanliness.
Avoid douching. In fact, they can be harmful to the vaginal microbiome and increases the risk of vaginal infections. In case of an unpleasant odor or abnormal discharge, it is best to consult a gynecologist.
Exercising the vaginal and pelvic muscles regularly. Orgasms are the best way to improve blood circulation and maintain healthy vaginal secretion!
What are the treatment options?
Although many formulations containing a host of skin care ingredients are marketed as remedies for vaginal dryness, it is best to adhere to medical recommendations because not all of these ingredients are tested for long-term safety and efficacy. Here are some widely prescribed treatment modalities for GSM. If other menopausal symptoms co-occur with GSM, the need for systemic hormone therapy (HT) may be evaluated.
The choice of treatment is subjective to your symptoms, severity and underlying medical conditions. It is important to openly discuss your medical history with your doctor so they can prescribe the best-suited treatment option(s) for you.
Water-based lubricants and moisturizers: These are available over the counter, can be used without a medical prescription. Products containing hyaluronic acid are known to be great for mild to moderate vaginal dryness.
Vaginal low-dose estrogen: Pessaries (vaginal tablets) and creams of very low-dose estrogen are used to ensure local action of estrogen and minimal absorption into the bloodstream. The amount of estrogen that enters circulation is almost negligible and hence this option is considered safe for high-risk candidates and as an add-on module for systemic HRT.
Vaginal DHEA (precursor of testosterone): Mainly prescribed for women with estrogen-sensitive breast cancer and those who are already on systemic HRT yet have genitourinary symptoms or sexual dysfunction (low libido).
Ospemifene: Binds estrogen receptors and activates them to provide symptomatic relief.
Some light- and energy-based therapy options (laser and radiofrequency) have shown promise in stimulating collagen production and the formation of new blood vessels in degenerated genitourinary organs in menopausal women. However, further research and data are necessary for them to be widely offered as treatment modalities for GSM.
Bear in mind…
Menopause symptom management is not a part of the medical curriculum in many regions (recently included in some countries), so many gynecologists may not be comfortable treating certain symptoms (especially if they are persistent) and can refer you to a urogynecologist or endocrinologist with specialization/ training in this area. Some experiences may test your perseverance. It is critical to keep up your hope, look out for empathetic medical practitioners and advocate for yourself. Only when there is a demand, more doctors will come forward to get trained in this specialty.
Disclaimer: Keep in mind that we may receive commissions when you click our links and make purchases. However, this does not impact our reviews and comparisons. We try our best to keep things fair and balanced, to help you make the best choice for you.
Disclaimer: Opinions expressed belong solely to the content provider. Miyara Women does not undertake any financial/reputational/legal/misrepresentational impact or other obligations/ liabilities that may arise from the content.
About the author
With 10+ years of experience in science communication, Dr. Ayshwarya Ravichandran ensures evidence and science-backed information are conveyed to women in understandable and comprehensible language and visualization. She is also a passionate women's health advocate engaging the Miyara community in different ways.
Opmerkingen