What Is Vaginal Atrophy? Women’s Doctors Explain

Estrogen is most closely associated with sexual and reproductive development in women, but this hormone affects systems throughout the body. Research, like this 2018 study on hormones and aging skin, suggests that estrogen levels peak when a woman is in her mid-to-late 20s, declining to about 50% by age 50—after which point it diminishes rapidly.

That’s why at the onset of menopause, women begin to experience a range of physical changes, both structural and aesthetic, from thinning hair and skin to weakening bones and blood vessels. Yet this drop in estrogen levels causes another extremely common condition called vaginal atrophy, and research published in The Journal of Sexual Medicine suggested that for the greater part of the past decade, 81% of women haven’t been aware vaginal atrophy is a treatable medical issue. Only a reported 72% have sought help for their symptoms.

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What is vaginal atrophy?

“Atrophy literally means drying up or shrinking,” says Alan Lindemann, MD, an obstetrician and maternal mortality expert. How this translates to vaginal health is that when a woman’s body has sufficient amounts of estrogen, the skin of the vagina is thick, robust, and stretchy—but “when estrogen is withdrawn, as in menopause, the skin of the vagina becomes thin, dried up, and not stretchy,” Dr. Lindemann says.

Diminishing estrogen levels also decrease vaginal blood flow and lubrication, says Helai Hesham, MD, an OBGYN, female pelvic medicine specialist and reconstructive surgeon at Columbia University Irving Medical Center. “The decrease in estrogen also causes downstream events that change the bacterial profile of the vagina.” This, she says, allows for more inflammation-causing bacteria to take hold.

These physical changes in the vagina lead to symptoms like dryness, irritation, soreness, and pain during sex, Dr. Hesham says. “Women can also experience urinary symptoms, including urinary frequency, urgency, urinary tract infections, and at times, incontinence.”

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How common is vaginal atrophy?

Due to the natural decline in estrogen levels, every female who undergoes menopause will experience some degree of vaginal atrophy, Dr. Lindemann says. And according to the National Library of Medicine, up to 57% will have symptoms severe enough to interfere with their daily lives.

Yet vaginal atrophy is “incredibly common and underreported,” Dr. Hesham says—the National Library of Medicine research explains that women are often reluctant or embarrassed to discuss their symptoms with their doctor, assuming that they’re just a normal part of aging.

In addition to post-menopausal women, an estimated 15% experience vaginal atrophy symptoms at a younger age. Women undergoing breast cancer treatment, who recently gave birth, or are breastfeeding are at risk, explains Dr. Hersham. “Women who have had their ovaries removed are also at risk, and women who have decreased sexual activity,” she says. Certain medications, like those used to treat uterine fibroids and endometriosis, may cause vaginal atrophy as well.

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How is vaginal atrophy treated?

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There are two standard approaches to treating vaginal atrophy, Dr. Hersham says: hormonal and nonhormonal methods. Nonhormonal methods include:

•  vaginal lubricants,
• vaginal moisturizers, and, more recently,
• vaginal laser therapy.

“Vaginal lubricants are short-acting and used primarily by patients shortly before sexual activity,” she says. “Vaginal moisturizers can be used to tackle dryness, itching, and pain with intercourse,” but she advises against using DIY solutions like Vaseline, vitamin E, or mineral oils. “Some use coconut oils [as a moisturizer], but patients do need to be careful with possible allergic reactions.”

Hormonal therapies are focused on localized vaginal estrogen therapy, she explains. “These come in cream, ring, and pill forms and are placed in the vagina at different frequencies.” Over time, this vaginal estrogen therapy restores the natural thickness of the vaginal walls, a healthy pH, normal blood flow, and a balance of good bacteria—mitigating symptoms. Oral hormone replacement therapy (HRT) is often prescribed to women who are having other menopausal symptoms—like hot flashes, mood changes, and sleep problems—and this can be helpful with vaginal atrophy symptoms. “But nearly 20% of patients will still need localized vaginal treatment, too,” she explains. Estrogen treatment, however, has been associated with some cases of female reproductive cancers and is not advised for specific groups of women, such as those who have had breast, uterine, or ovarian cancer or have a history of blood clots. In these cases, non-estrogen oral medications called selective estrogen receptor modulators can treat vaginal atrophy.

“Vaginal laser therapy is a newer technology that has also been used to localize therapy to the vagina, particularly for women who have either failed estrogen therapy or are not candidates for vaginal estrogen,” Dr. Hersham adds.

Still, there are some ways you can lower your personal risk for vaginal atrophy symptoms. Studies show cigarette smoking is associated with poor vaginal health—and because it affects your circulation, it can reduce the flow of blood and oxygen to your vagina. A healthy diet also plays a major role in vaginal health, as does maintaining an active sex life as you age, either with a partner or flying solo. (Read more about how one woman revived her sex life post-menopause.)

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Dr. Allison Chase, PhD, CEDS-S, is the regional clinical director for Eating Recovery Center and Pathlight Mood & Anxiety Center in Denver, CO.