Vaginal dryness

Dryness, soreness or irritation in and around the vagina, which often starts in perimenopause and carries on after menopause.

Doctors have a longer name for the whole group of changes: genitourinary syndrome of menopause, or GSM. NICE NG23 describes these symptoms as dryness, pain with sex, discomfort or irritation, and discomfort or pain when passing urine. The Pakistan Menopause Society notes that GSM replaced older terms such as vulvovaginal atrophy.

The NHS website lists feeling sore or itchy in and around the vagina, pain or discomfort including during sex, needing to pee more often, getting urinary infections again and again, and unusual discharge, spotting or bleeding.

Women's Health Concern adds what the lists leave out. It can be uncomfortable to sit, to stand, to exercise, even to work. A smear test can become harder. Discharge can change and burn a little, and many women take it for thrush, buy something over the counter, and make it worse.

Women's Health Concern explains that after menopause the ovaries stop making estrogen, and without it the skin of the vulva and vagina becomes thinner, less elastic and drier. Less natural lubrication during sex is one of the early signs.

The NHS website lists other causes too: breastfeeding, some medicines including hormonal contraception and antidepressants, a hysterectomy, cancer treatment, perfumed soaps and washes, and conditions such as diabetes.

The NHS website suggests:

• water-based lubricants before sex
• vaginal moisturisers, used inside the vagina to keep it moist
• unperfumed soaps and washes around the vagina, and no douches

The Pakistan Menopause Society adds that moisturisers can be used regularly, daily or several times a week, rather than only at the time of sex, for a longer-lasting effect, because they rehydrate the tissue (section 6.2).

The Menopause Society suggests trying a new lubricant or moisturiser on a small patch of skin first. If it suits your skin but still stings inside, it suggests switching to a silicone-based product, or one labelled iso-osmolar or free of propylene glycol. It also says herbal products appear not to help vaginal dryness.

NICE NG23 and the British Menopause Society both give two kinds of option: vaginal estrogen, and moisturisers or lubricants.

NICE NG23 recommends offering vaginal estrogen, as a cream, gel, tablet, pessary or ring, with regular reviews. It tells doctors to explain that serious side effects are very rare and that symptoms often return when it is stopped, though it can be restarted (1.5.5 to 1.5.7). It lists vaginal prasterone if vaginal estrogen or moisturisers have not worked or do not suit, and ospemifene, a tablet, for women who cannot easily use treatments applied locally (1.5.10 and 1.5.11).

The British Menopause Society's statement on GSM adds that lubricants and moisturisers can be used alongside vaginal estrogen, and matter most for women who cannot use it.

For women who have had breast cancer, NICE NG23 recommends non-hormonal moisturisers or lubricants first (1.5.14). Which route suits you is a decision for you and your doctor.

The NHS website says to see a GP if dryness has lasted a few weeks and what you have tried is not working, if it is affecting your daily life, if you have unusual discharge, or if you bleed after sex, between periods or after menopause. That last one always needs checking: see bleeding after menopause.

If itching is the main problem, say so. The European Menopause and Andropause Society (EMAS) describes lichen sclerosus, a long-term skin condition of the vulva that mainly itches and can make sex painful. EMAS says hormone creams, estrogen included, are not recommended for it, so it needs telling apart.

The Pakistan Menopause Society notes that many Pakistani women may not mention sexual or urinary symptoms unless a doctor asks respectfully and in private (section 2.2). So you may have to raise it yourself. Women's Health Concern suggests writing it down and handing the note over if saying it feels impossible. The word takleef is enough to begin.

Women's Health Concern also notes the strain dryness can put on a relationship when a woman feels unable to tell her partner why she is not interested in sex. Telling him it is the menopause, and not him, is often the hardest sentence and the most useful one.