What’s going on down there? Painful vulvas, vaginas and bladder issues

“How’s your vagina?”

 It’s not a question many of us have probably ever been asked by a doctor, but as we head into our 40s and beyond, it’s a topic we probably should be bringing up more ourselves in the GP’s office. That’s because things change, ‘down there’, as we age, and getting more comfortable talking about it can help us potentially avoid a lot of pain and discomfort.

 If you’ve noticed a change in how your vagina feels – maybe it’s drier; a bit painful during sex; itchy or uncomfortable – or you’re feeling like you might have recurring UTIs or thrush-type symptoms, it’s likely all part of what happens to us at midlife.

 Just as the skin on our faces and bodies changes, the skin and tissue of our vulvas, vaginas and urethras do, too, as the oestrogen in our bodies declines at midlife and we hit perimenopause and menopause.

 Endocrinologist and menopause expert, Dr Anna Fenton, explains:

 “Without the estrogen, the lining of the vagina, the lining of the urethra and the skin on the outside round the vulva - everywhere, really from the clitoris all the way back to the anal area - that skin thins. So it's very easy to split. You get shrinkage of the soft tissue on either side of the vulva, then inside the vagina, you get a whole range of changes. It gets drier, the lining layer thins back. So the cells aren't nice and plumped up and well lubricated. You're seeing much the same going on in the urethra as well.”

 This can cause symptoms that are no fun: pain, itching, inflammation and bleeding. And obviously this can lead to issues with sex and relationships; it’s no surprise that libido will tend to disappear if sex is painful.

 It can also lead to symptoms we might not think are related. Many women report what they think are recurrent thrush or bladder infections, but in fact are inflammatory reactions to hormone-driven change.

 If this sounds like you, you’re not alone.

 “It happens to every single woman on the planet as the estrogen drops after menopause”, say Dr Fenton.

 And it gets more and more common as we age.

 “By the time we're four or five years down the track from periods having stopped, probably 40 to 50% of women will have some symptoms. And everyone at some point will notice them”.

 There’s a name for this: Genitourinary Syndrome of Menopause (GSM). That’s only slightly better than its old name, the horrifying-sounding Vaginal Atrophy. I think we can agree these terms don’t encourage us to chat about this!   

 The good news is that even though GSM is probably inevitable, if we can summon up the courage to talk about it, it’s also highly sort-able. We don’t have to just put up with it.

“There's plenty of ways to manage this”, Dr Fenton says. “It's just that women are often too embarrassed to bring it up”.

 To start with, there are lubricants and vaginal moisturisers, which can be bought over the counter (or online if the idea of asking for lube at the chemist is just too much). Moisturisers are useful because while lube is used during sex, moisturiser can be used a couple of times a week and stays in the vagina, keeping it moist and giving ongoing comfort. It’s also good if we’re not in the habit of scheduling sex.

“It's not a kind of last-minute, grab the tube of KY jelly thing”, says Dr Fenton.

 If those are not enough, the next step is vaginal oestrogen. This is applied as a cream or pessary, directly into the vagina, and is used at first every day, and then a few times a week. Adding oestrogen directly to the vagina replenishes the tissues and plumps everything back up, and usually sorts out GSM issues. Oestrogen applied this way is very safe (despite what the packet insert says, apparently – Dr Fenton says this is a global bugbear of menopause specialists).

 “This [vaginal oestrogen] is only going to affect the local area down around the vagina and the vulva. After the first few days of use the absorption beyond this area is very low. Good research has shown that it’s very safe. You can use it for as long as is needed”, she says.

 So while it might be tricky, talking about our vaginas is well worth any embarrassment. After all, as Dr Fenton says, if we don't do something about it, “it's just going to turn into the Sahara down there”.

 And nobody wants that!

There’s a lot more on this issue in This Changes Everything, chapter 7: Viva la vulva (and vagina) - pain, dryness, bladder issues and more.