Keep Your Menopausal Vagina Healthy and Happy

Pain and discomfort down there is common. You don’t have to live with it.

By Selene Yeager  

Of all the changes and challenges that menopause can bring, vulvovaginal atrophy (VVA), which falls under the genitourinary syndrome of menopause (GSM), is among the most common and bothersome, impacting up to 90 percent of women, depending on the studies your read. And unlike other symptoms that can abate overtime, with or without therapy, vaginal pain, dryness, and irritation doesn’t disappear and often only worsens, because it results from physical changes in those tissues.

As with many of the changes surrounding menopause, these changes are connected to estrogen loss. Estrogen promotes blood flow to the pelvis and keeps your vaginal walls thick, elastic, and moist and maintains the integrity of the vulvar tissues. Without it, the tissues become drier, thinner, less elastic, and more fragile. That, as many women find out the hard way, can make sex suddenly painful. It can also cause general discomfort, itching, burning, and irritation during daily life and can take the joy out of general activities like riding a bike. As if that weren’t enough (and it surely is), these changes also can lead to urinary symptoms like incontinence and urinary tract infections (UTIs), as well as sebaceous cysts and other conditions.

The good news is that these GSM-related changes are very treatable, as Rochelle Bernstein, MD, of Purely Menopause explained on this week’s episode of Hit Play Not Pause. That means you can keep those tissues healthy, comfortable, and pain free so you can stay active for life. Here's what she, and recent research, recommend.

TLC for Your Sensitive Tissues

The earlier you start treating GSM the better. Research shows that earlier (i.e. before age 60) initiation of treatment leads to a more robust and rapid response. You might have a less robust response after age 60, but importantly, you can still get relief from your symptoms no matter when you start. Here’s what to consider.

Local Hormone Therapy

Vaginal estrogen is considered the gold standard, most effective treatment for GSM. It improves the quality of the tissues in and around the vagina, thickens the skin of the canal, increases natural lubrication, and restores normal pH of the vagina. Research shows it also reduces the risk of UTIs. It’s also safe for most women, even those who have had breast cancer. Note, you may need local estrogen even if you’re on hormone therapy.

“Hormone replacement therapy can help with vaginal symptoms, but oftentimes it’s not enough,” says Bernstein. “You still need to be paying attention to the skin down there.”

Some women also find relief from a non-estrogen treatment called Intrarosa (prasterone), which is a vaginal DHEA suppository that's inserted daily. 

Hyaluronic Acid

For women who cannot or do not want to use local hormone therapy, hyaluronic acid (HLA), which you can find in products like Revaree, can help reduce vulvovaginal symptoms like itching, burning, and dryness. A study presented at the 2023 Menopause Meeting (you can check it out here, poster P-1) found that women using HLA enjoyed similar symptom relief, as measured using the Vulvovaginal Symptom Questionnaire (VSQ), as those using vaginal estrogen cream. Some women (yours truly included) like to use both, especially if they do long distance cycling or otherwise need extra tissue care.

Gentle Hygiene

When you have GSM, you may experience pain, burning, odor, and recurrent vaginal infections. This does not mean that you’re “unclean” or that you need special soaps, cleansers, or steam machines, as a lot of persistent, terrible, predatory marketing will tell you. Taking care of those tissues to make them healthy again will help. Also just pay attention to basic hygiene. Get out of your workout clothes, especially tight, sweaty ones like bike shorts, as soon as you’re done working out, and wash up normally with water and gentle cleanser.

If you feel like you need some extra relief from itching and burning, Bernstein says you can try a boric acid vaginal suppository, which helps promote a balance of acid in your vagina.

Smart Bicycling

If you ride a bike (including avid Peloton users), be sure to wear shorts with padding that is comfortable and doesn’t rub or aggravate you anywhere. Your bike seat should also support your sit bones and have a built-in channel that runs along it, so it supports you without putting pressure on your sensitive tissues. A professional bike fit is always a good idea as well.

Easy On the Waxing

We have pubic hair for a reason, says Bernstein. It helps keep the skin of the vulva warm and moisturized and protects the delicate skin from friction (especially during cycling). It also can help prevent the transmission of bacteria and other germs that you don't want in there. If you like to wax, consider keeping some of the hair for protective purposes.