Vaginal atrophy means the vaginal walls (and often the vulvar and urinary tissues) become thinner, less elastic, drier, more fragile, and less optimally vascularized. It leads to symptoms such as vaginal dryness, burning or itching, pain with intercourse (dyspareunia), bleeding with sex, urinary urgency/frequency, recurrent urinary tract infections, and changes in vaginal pH and flora. Because the condition often involves both vaginal and urinary tissues, it is increasingly described under the broader term GSM (Genitourinary Syndrome of Menopause).
During the perimenopause and menopause transition, ovarian production of estrogen drops significantly. This decline is a primary driver of vaginal atrophy.
Estrogen helps maintain the thickness and elasticity of the vaginal epithelium, supports the vaginal lubrication, promotes the glycogen-rich superficial cell layer (which helps support healthy lactobacillus flora and acidic pH), and supports blood flow in the tissues. Without sufficient estrogen, the epithelium becomes thinner, fewer superficial cells are present, less glycogen is available, lactobacillus populations drop, vaginal pH rises, dryness and fragility increase.
The vaginal connective tissue may lose collagen and elastin, become less well perfused, and the mucosa may become less hydrated and more prone to micro-trauma.
These changes reduce natural lubrication, make intercourse more likely to be painful, lead to urinary changes (because the surrounding tissues and urethra/vaginal vestibule are involved), and increase vulnerability to infections and tissue damage. F
Because these changes often occur gradually, many women don’t recognize them as linked to menopause and may blame themselves or assume it is “just part of aging” rather than a treatable condition.
Vaginal moisturizers (used regularly, e.g., multiple times per week) and water-based or silicone-based lubricants at time of sexual activity help relieve symptoms.
Regular sexual activity (or use of vaginal dilators) may help maintain tissue elasticity and blood flow. Mayo Clinic
Optimizing general genital health (avoiding irritants, maintaining good blood flow, managing other health conditions) supports vaginal tissue health.
Low-dose local vaginal estrogen (cream, ring, tablet) is well supported and is considered first-line pharmacologic treatment for moderate-to-severe symptoms of vaginal atrophy/GSM. These deliver estrogen directly to the tissues with minimal systemic absorption. PMC JAMA Network
Vaginal DHEA (prasterone) inserts and oral selective estrogen receptor modulators (e.g., ospemifene) are also options depending on individual risk profile and symptom severity. Mayo Clinic
Systemic hormone therapy (estrogen ± progestin) may be appropriate when vaginal atrophy co-exists with other menopausal symptoms (e.g., hot flashes, bone loss), and must be individualized. PMC
Hyaluronic acid vaginal preparations have shown benefit (systematic review) for post-menopausal vaginal atrophy, especially in women who cannot or prefer not to use estrogen. OUP Academic
Oxytocin vaginal gel shows early promise in RCTs — though more research is needed. BioMed Central+1
Addressing barriers to care (education, provider communication) is important; many women don’t seek help even though they have symptoms. PubMed+1
Vaginal atrophy is not an inevitable “just part of aging” condition — it is a treatable consequence of the decline in estrogen (and other hormonal, vascular, and tissue changes) in midlife. It is most likely to worsen over time, GSM does not resolve on its' own.
Early recognition matters: untreated GSM can impact sexual health, urinary health, quality of life, and may contribute to ongoing tissue damage.
Multiple treatment options exist — from non-hormonal self-care to well-studied local hormonal therapies — and care should be individualised, especially in women with contraindications to systemic hormones.
Open dialogue, provider awareness and patient empowerment are key to getting timely help.
Crandall CJ. Treatment of Vulvovaginal Atrophy. JAMA Network. 2020; “Treatment of Vulvovaginal Atrophy.” JAMA Network
Frontiers in Reproductive Health. “Genitourinary Syndrome of Menopause: Epidemiology, Physiopathology, Clinical Manifestation and Diagnostic.” 2021. Frontiers
Albalawi N, Almohammadi M, Albalawi A. “Comparison of the Efficacy of Vaginal Hyaluronic Acid to Estrogen for the Treatment of Vaginal Atrophy in Postmenopausal Women: A Systematic Review.” Cureus. 2023. Cureus
Kingsberg SA, Kellogg S, Krychman M. “Treating dyspareunia caused by vaginal atrophy: a review of treatment options using vaginal estrogen therapy.” International Journal of Women’s Health. 2009. Dove Medical Press
“Resistance and barriers to local estrogen therapy in women with atrophic vaginitis.” PubMed. 2013. PubMed
Campagnaro M. dos Santos et al. “Hyaluronic Acid in Postmenopause Vaginal Atrophy: A Systematic Review.” Journal of Sexual Medicine. 2021;18(1):156. OUP Academic
Mayo Clinic Staff. “Vaginal Atrophy – Symptoms & Causes.” Mayo Clinic. 2021. Mayo Clinic