The menopause symptom you might not of heard about
The most widely known symptoms of menopause are hot flushes and mood swings, but over half of menopausal women also experience bothersome genito-urinary symptoms. Femma GP Dr Sophie Genoni discusses what causes these symptoms and what you can do about them.
Menopause is the cessation of periods and occurs on average around the age of 51 in Australian women. A woman’s periods will stop when the ovaries run out of eggs for ovulation, which means the ovaries are no longer active and she will not produce the same amount of oestrogen as before. The genito-urinary system, which includes the vulva, vagina, urethra and bladder, is sensitive to oestrogen levels and will undergo changes when the levels are low.
Similar genito-urinary symptoms of low oestrogen can also occur in women who are breastfeeding and women on hormone suppressing treatments for breast cancer.
The tissue of the vagina and vulva are designed to be thick, pliable and flexible, and is highly dependent on oestrogen levels to maintain these characteristics. During the menopausal transition when oestrogen levels are lower, and particularly after the menopause, the vaginal and vulval tissues change in response to the lack of oestrogen. The tissues become thin, less flexible and friable (easily damaged). These changes unfortunately do not improve with time, as the oestrogen levels continue to remain low after the menopause. These changes to the vulval and vaginal tissues are referred to as ‘atrophic vaginitis’
The changes to the tissues cause symptoms such as:
- Discomfort – which may be a feeling of burning, irritation or mild itch
- Thinning of the tissues that may lead to splits or fissures
- Shrinking of the labia and clitoris
The sexual symptoms of menopause are impacted by several factors – the physical genital symptoms, the impact of low oestrogen on libido, and other changes during menopause such as mood and reduced energy levels. The changes to the genital tissues often lead to physical discomfort during sex. The dryness and lack of lubrication causes discomfort and pain, and can result in splitting or bleeding of the tissues during sex. This can cause the experience to be uncomfortable, or result in women being hesitant to engage in sexual activity in anticipation of discomfort.
Libido is the term used for women’s sexual drive, and includes the desire to have sex and the satisfaction or pleasure experienced from sexual activity. Libido is complex, and influenced by many factors, and most women will experience low libido at some point in their lives. There is no right or wrong level for a woman’s libido, so saying a woman has ‘low libido’ simply means that her libido does not match what she would like it to be. The low oestrogen in menopause changes the brains desire for sexual activity, which can also be further influenced by the mood changes that occur during menopause. The changes to the vaginal, vulval and clitoral tissues may decrease the desire for sexual activity, as well as reduce the pleasure experienced. The physical discomfort caused by atrophic vaginitis can impact the experience and subsequently create less desire.
The changes to the vulval and vaginal tissues also affect the urethra and bladder opening. This can lead to urinary symptoms such as urgency (a feeling of needing to empty the bladder urgently), incontinence (not being able to hold the bladder), and sometimes discomfort or pain with urinating. This is further impacted by weakening of the pelvic floor muscles with age or due to previous pregnancy.
The lower oestrogen levels also affect the balance of bacteria in the vaginal and vulval tissues. This, along with the changes to the tissues of the urethral opening, can result in bacteria entering the urethra more easily and causing a urinary tract infection (UTI). UTIs are more common in post-menopausal women, and some women may develop recurrent urinary tract infections after menopause.
Lifestyle treatment options
Some simple lifestyle measures can improve symptoms, such as wearing breathable cotton underwear, avoiding heavily fragranced laundry products, washing the genital area only with water and avoiding soaps and feminine hygiene creams or sprays, avoiding shaving and waxing, and reducing or quitting smoking. Patting dry after urinating rather than wiping can minimise irritation to the tissues.
Pelvic floor exercises can improve the function of the pelvic floor and reduce symptoms of urgency and incontinence.
Over-the-counter treatment options
Vaginal moisturisers can be used on a regular basis to help improve moisture levels in the vaginal and vulval. These moisturisers provide a temporary boost to moisture rather than changing the tissues, so they require repeat use to maintain the moisture levels. Vaginal lubricants can be used to improve comfort during sexual activity.
Other feminine hygiene products such as washes, pH balancing creams or sprays and probiotics have not been shown to be required or beneficial, and can occasionally worsen symptoms. Other oils and ointments may contain substances which cause further irritation so are best avoided.
Prescription treatment options
Topical vaginal oestrogen replenishes the oestrogen levels to the vulval and vaginal tissues directly. These are available in creams or pessaries (a type of tablet inserted into the vagina). Very little is absorbed into the body so these are usually quite safe for most women.
Systemic menopausal hormonal therapy (MHT) improves oestrogen levels throughout the whole body, so can improve genito-urinary symptoms, as well as other factors impacting symptoms such as low libido and mood. MHT is usually considered in women experiencing hot flushes and other vasomotor symptoms, and comes with more considerations than topical oestrogen products.
Some prescription medications can actually cause or worsen vaginal dryness or bladder symptoms. If you feel this may be the case, you could discuss with your GP whether there are other medication options to consider.
Vaginal laser therapy has not been approved for the treatment of menopausal genito-urinary symptoms as there is not sufficient safety data. There is also no conclusive evidence that it is effective for treating genito-urinary conditions such as atrophic vaginitis.
When to see your GP
You should check in with your GP if:
- You are experiencing genito-urinary symptoms that are impacting your day to day function
- You experience frequent urinary tract infections
- You have excessive itching, a rash or abnormal vaginal discharge
- You experience any vaginal bleeding after menopause
- You are concerned about your genito-urinary symptoms for any other reason