Vaginal atrophy

What is vaginal atrophy?

Vaginal atrophy is the thinning of your vaginal lining and vulval skin, caused by a drop in oestrogen levels around the time of menopause. Vaginal atrophy affects about 40% of postmenopausal women – and the risk increases with age.

Symptoms

Symptoms include:

• vaginal dryness
• painful sex (dyspareunia)
• reduced vaginal lubrication during sex
• burning and itching in the vagina
• vulval irritation, especially when wearing tight pants or Lycra
• smelly vaginal discharge (sometimes mistaken for thrush)
• shortening and tightening of the vagina
• pale and thin labia (lips) and vagina
• reduced pubic hair
• spotting or light bleeding, including after sex – if this happens, see your doctor straight away.

Urinary symptoms include:

• frequent or urgent need to wee
• pain or burning sensation when weeing
• weeing more often than usual, including at night
• blood in your wee
• wee leakage (urinary incontinence)
• recurrent urinary tract infections (UTIs).

The risk of UTIs increase as you age. Weakened pelvic floor muscles can make it hard to control your wee. When your bladder doesn’t empty completely, a ‘pool’ of wee may be left behind, which can lead to infection. Also, after menopause, your vagina becomes less acidic, which allows bacteria and other organisms to grow and thrive. This can increase the risk of UTIs.

Causes

The vagina, and other tissues in the pelvis, need oestrogen to stay healthy. When oestrogen levels drop (around the time of menopause), the tissues become drier, thinner and more fragile. This can increase the risk of irritation and UTIs.

Oestrogen levels may also decrease due to:

• breastfeeding
• medicine that stops or reduces oestrogen levels (e.g. oral contraceptives)
• the surgical removal of both ovaries (surgical menopause)
• pelvic radiation therapy for cancer
• chemotherapy
• hormonal breast cancer treatment.

Diagnosis

Vaginal atrophy is usually diagnosed via a clinical examination. Your doctor will ask about your symptoms and medical history. They should check your vulva and vagina for signs of atrophy. If you have vaginal discharge, your doctor may take a vaginal swab to check for infection. If you have urinary symptoms, they may also order a urine (wee) test to check for a UTI.

Risks and complications

Women over 50 years of age or women who have gone through menopause are most likely to develop vaginal atrophy. But other factors can increase your risk.

For example, if you:

• have had your ovaries removed
• have had chemotherapy or radiation treatment
• are not sexually active – sex increases blood flow to the area and makes vaginal tissues more elastic
• have an immune disorder
• take medicines that affect oestrogen levels
• haven’t given birth vaginally
• smoke.

Treatment and management

Depending on your situation, you may want to try hormonal treatments.

Vaginal oestrogens

Vaginal oestrogens are available as tablets, pessaries or creams. They are an effective treatment for vaginal atrophy. They deliver oestrogen directly to the vagina without raising oestrogen levels in the rest of the body. Vaginal oestrogen treatment improves blood flow in the pelvis and increases vaginal secretions.

Oestrogen tablets and creams come with an applicator, but you may find it easier to apply the tablet or cream to your finger and insert it into your vagina. Any excess can be smeared onto the skin of your vulva. You should only insert the oestrogen about two or three centimetres into your vagina. This will improve the health of your pelvic tissues, including your vulva, vagina, bladder, urethra and pelvic floor muscles.

Menopausal Hormone Therapy (MHT)

MHT may improve vaginal symptoms and other menopause symptoms, such as hot flushes and night sweats.

Hormonal treatment may not be suitable if you have a history of cancer with receptors that use oestrogen to grow (oestrogen-receptor-positive cancer). Discuss the risk factors with your doctor.

Can vaginal atrophy be reversed?

You cannot reverse vaginal atrophy, but you can stop it from getting worse by seeking a diagnosis and starting treatment early. Research suggests that MHT eliminates vaginal atrophy symptoms in 75% of cases, while vaginal oestrogen therapy is effective in 80% to 90% of cases. Without treatment, vaginal atrophy may get worse over time.

What you can do

It’s important to take extra care of your vulva and vagina when managing this condition. For example, use a soap-free wash, avoid tight-fitting clothes and try not to rub or scratch affected areas.

Learn more about vulval care.

You can also try:

• Cold compresses – to help with itching and mild discomfort. Dilute half a teaspoon of bicarb soda in one litre of water, soak a washcloth in the solution and apply it gently to your vulva a few times a day, taking care to pat the area dry (instead of rubbing) afterwards.
• Water or silicone-based vaginal lubricants – to make sex more comfortable. But don’t use oil-based lubricants with latex condoms as they can damage the condom.
• Non-hormonal moisturisers (e.g. Replens®) – to help to ‘plump up’ and add moisture to cells in your vagina.
• Flaxseed – some research suggests it may help with vaginal dryness. Grind the flaxseed and add two tablespoons to your cereal, salad or smoothies each day.
• Regular sexual activity (including masturbation) – to improve blood flow to your vagina, which can keep vaginal tissues elastic and flexible. Sexually active women report fewer symptoms of vaginal atrophy compared to women who don’t have regular sex.

When to see your doctor

Many women have symptoms of vaginal atrophy (such as painful sex) but they don’t seek treatment because they feel embarrassed or think nothing can be done. It’s important to get the right diagnosis and treatment, so see your doctor if you have any symptoms.

Related resources

Download our fact sheets or visit resources for more information, including translated fact sheets.

This web page is designed to be informative and educational. It is not intended to provide specific medical advice or replace advice from your health practitioner. The information above is based on current medical knowledge, evidence and practice as at April 2023.