Itch, dryness, pain, irregular bleeding: in midlife and menopause and our post-menopausal years, vaginal issues are common, but women don’t have to live with the discomfort and inconvenience. And we shouldn’t – some vaginal issues, like bleeding after menopause, can be indicators of more serious conditions.

Dr. Rebecca Dunsmoor-Su

Dr. Rebecca Dunsmoor-Su

We asked our Director of Health, OB/GYN Dr. Rebecca Dunsmoor-Su, to help us identify some of the common concerns, explain what’s happening, and let us know what we should be doing next.

If you have additional questions, please contact your own doctor (especially if urgent), or send us an email at, and we’ll follow up with Dr. Dunsmoor-Su.

One: What are the most common vaginal issues women experience in menopause?

Well, that is a good question. First of all, no two women are alike. What I find as a physician is that the experience of menopause is different for everyone, even though I may be seeing very similar signs when I do an exam.

With that being said, I find the most common complaint I get is vaginal dryness. Women find that they feel dry day to day, sometimes with itchiness. They feel dryer during intercourse and sometimes even lubes aren’t enough to help with that feeling.

Along with dryness I see a lot of women who have pain with intercourse. These two things are related, and are due to the change in the mucosa of the vulva and the vagina with the reduced estrogen circulating. I find that women who have an abrupt shift into menopause (either due to surgery or breast cancer treatment) often have the worst of these symptoms. This may be due to the abrupt change instead of gradual adjustment.

Do you experience pain with sex? Discover causes and solutions: watch Gennev's Painful Sex webinar.

Things that women don’t realize are due to the vaginal changes – but which can be very bothersome – are urinary symptoms. This can be due to the overall changes in the vaginal mucosa which leave the urethra (the tube that carries urine from the bladder to the outside) or the bladder itself unsupported. Frequent urinary or vaginal infections can also occur due to the change in the bacteria that live in the vagina.

Vulvar conditions

Rarely there can be additional vulvar conditions that can exacerbate these symptoms, called Lichen sclerosus and Lichen planus, but these are uncommon, and a separate topic.

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Two: What exactly is happening in a woman’s body during menopause to cause these changes?

facts about menopause

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As estrogen levels decline with menopause, the tissues that respond to estrogen all change. We notice the change in the uterine lining because we stop having periods as that lining thins out. The vaginal and vulvar tissues also get thinner as the estrogen goes away.

Before menopause, estrogen causes the layers in the walls of the vaginal to be thick and elastic. There are lots of collagen molecules (giving elasticity), hyaluronic acid, and blood vessels bringing in moisture. Glycogen is created by the cells in the walls of the vagina. Because of the structure of the walls, the top layer of the vaginal wall breaks away on a regular basis, and the lactobacilli (the good guys) eat that glycogen and help keep the pH of the vagina low (acidic). This keeps away other bacteria and yeast.

All of the above things that keep the vagina plump rely on the stimulus of estrogen. Once the estrogen levels drop, the tissues become thinner and less elastic. When we do biopsies, we see very thin tissue with few layers. The moisture, collagen and acid production shrink significantly. Lactobacilli can no longer survive in the vagina, so other bacteria come in and replace them, and these are sometimes not such “good guys.” A lot of women notice increased discomfort and / or decreased sensation due to these changes.

Three: At what point should a woman talk to her doctor about vaginal problems she’s experiencing? Are any of these potentially dangerous?

If the symptoms are bothering you, talk to your doctor. There are many levels of therapy that can be helpful.

If your doctor is uncomfortable talking about sexual or vaginal issues, or does not have specific training in treating women in menopause, an OB/GYN is the specialist you want to see. We all have hormone and menopause training, though some may have more comfort than others with the topic. When you call, don’t be shy about asking for someone who sees menopausal patients on a regular basis.

Find a practitioner via the North American Menopause Society 

In general, vaginal changes aren’t dangerous. However, if women simply assume their symptoms are due to menopause alone, they may miss other disease processes. It is especially important to see your physician if you have a history of HPV or abnormal pap smear, as this virus can cause cancer on the outside and in the vagina as well.

As mentioned before, sometimes the irritation is not just menopause but a more severe disorder such as lichen sclerosis, which must be treated to prevent long-term damage. A good exam by an experienced provider can help sort these out.

Four: What should women be looking out for and paying attention to, when it comes to their bodies? Are there early warning signs women should be aware of?

Well, that’s a broad question. It is important to recognize that our bodies change with age and with menopause. While all of the changes that come can be normal, we may not like some of them. Sometimes it is important to recognize what is normal versus what is abnormal, or ”pathologic,” as we like to say in medicine.

In terms of symptoms:

  • Bleeding after you have had no period for a year (are in menopause) is NOT normal. It can be just due to thin lining or even the vagina, but it ALWAYS needs to be evaluated to rule out cancer.
  • Pain with intercourse, lack of desire, changes in sensation in the vaginal region and vulva can all be “normal” but they are not functional and not OK. You should feel free to bring this up with your doctor and have a frank discussion about what can be done to make sure your sex life continues to be an important part of your life and health.
  • Day to day itching and dryness in the vaginal region can also be normal, but if it is impacting your daily life, it can be treated with multiple different modalities.
  • Hot flashes and night sweats are a normal part of the menopausal transition for some women, but if they impact your life, we can talk about lifestyle changes and treatments that may help.

Five: Women are often embarrassed by the changes in their bodies. How do you put women at ease to have these conversations?

First and foremost you need to be seeing a provider with whom you feel comfortable to have any conversation. Remember, as physicians,we have heard it all! We are not afraid, in general, to tackle difficult subjects.

If you find that your physician struggles with talking frankly about the more sensitive stuff, or has a lack of knowledge about menopause in particular, seek out someone who is comfortable with it, usually an OB/GYN. We talk about sex all the time….

Six: Do you think doctors should ask women about their sex lives, or is it better to wait for the woman to bring it up?

Well, I think we doctors should be bringing it up, but I specialize in menopause and spend a lot of time talking frankly about sex, lube, treatments, and toys, etc. It takes time and research to learn about these things, and many providers did not get great training on how to approach these subjects.

If your doctor isn’t asking, ask them! They can’t help you if they don’t know that sex is an issue.

In “vaginal issues in menopause: Q&A with an ob/gyn (part 2)” Dr. Dunsmoor-Su takes on treatments (hormonal, non-hormonal, laser therapy), addresses the fears women have about HRT and bio-identical hormones, talks about alternative therapies such as acupuncture, herbs, and OTC remedies, and discusses her thoughts on how doctors should be trained to understand and treat menopausal issues and the women who are looking for help. 

If you’re suffering from vaginal issues, don’t hesitate to talk with your doctor. Please don’t use this blog or any similar online resource to self-diagnose: articles such as this should not be considered a replacement for treatment by a healthcare professional.

Have you had vaginal issues? What happened, and how are you putting things right? We’d love to hear from you, so please share in the comments below (you can share anonymously, if that’s more comfortable for you), on our Facebook page, or in Midlife & Menopause Solutions, our closed Facebook group.