Menopause Myth #17: Vaginal Dryness Isn’t ‘Just Part of Getting Older’: It’s Treatable

“I thought I just had to live with it.”

A 56-year-old woman sits in front of me, clearly uncomfortable discussing the topic. She’s been post-menopausal for four years. She came in ostensibly to discuss her HRT (which she stopped two years ago because “I didn’t think I needed it anymore — my hot flushes had stopped”).

But as we talk, the real reason for her visit emerges.

“Sex has become… impossible,” she says quietly. “It’s so painful. I feel like I’m being torn. Even just trying causes burning and stinging. We’ve stopped even attempting because it’s so awful.”

She tears up. “My partner is understanding, but I know he’s frustrated. I’m frustrated. I miss that connection. But I can’t face the pain.”

She pauses. “And it’s not just sex. I need to pee constantly — like every hour. I get frequent UTIs. Sometimes I leak a bit when I cough or sneeze. Everything down there feels dry, itchy, uncomfortable.”

“Have you spoken to your GP about this?” I ask.

“Yes. I was told it’s just part of getting older. That vaginal dryness is normal after menopause. He suggested using lubricant during sex. But lubricant doesn’t help — it’s not just about wetness during sex. Everything is dry, thin, sore all the time.”

This conversation breaks my heart — because what she’s experiencing is absolutely treatable.

Vaginal dryness and the constellation of symptoms known as Genitourinary Syndrome of Menopause (GSM) are NOT “just part of getting older” that you have to accept.

They’re caused by oestrogen deficiency. And they can be dramatically improved with topical oestrogen — a safe, effective treatment that many women don’t know exists.

What Is Genitourinary Syndrome of Menopause (GSM)?

GSM is the medical term for the collection of symptoms caused by oestrogen deficiency affecting the genital and urinary tissues.

Previously called “vulvovaginal atrophy” or “atrophic vaginitis,” the term was changed to GSM because:

It encompasses urinary symptoms (not just vaginal)
“Atrophy” sounds frightening and irreversible (it’s not — treatment reverses it)
GSM is more comprehensive and less stigmatizing

What Causes GSM?

Declining oestrogen after menopause causes:

Tissue changes:

Vaginal lining becomes thinner (loses layers of cells)
Less elastic, more fragile
Reduced blood flow
Reduced natural lubrication
Vaginal pH changes (becomes less acidic, more prone to infection)
Vulvar tissues thin and lose elasticity

Urethral and bladder changes:

Urethral lining becomes thinner
Bladder lining more sensitive
Pelvic floor tissues weaken

These changes cause symptoms.

GSM Is Progressive:

Unlike hot flushes (which often improve over time), GSM worsens without treatment:

Symptoms develop gradually over years
Start with mild dryness
Progress to painful sex, urinary symptoms, chronic discomfort
Don’t improve on their own — ongoing oestrogen deficiency means ongoing tissue changes
Won’t resolve without treatment

This is important: If you ignore GSM hoping it will get better, it won’t. It will progressively worsen.

Symptoms of GSM

GSM causes a wide range of symptoms affecting sexual function, urinary health, and comfort:

Sexual Symptoms:

Vaginal dryness:

Lack of natural lubrication
Feeling dry all the time (not just during sex)
Uncomfortable, itchy sensation

Painful sex (dyspareunia):

Burning, stinging, tearing sensation during penetration
Pain during or after sex
Bleeding during or after sex (from fragile tissue)
This is often the most distressing symptom — profoundly impacts relationships and quality of life

Loss of arousal:

Reduced genital sensation
Difficulty becoming aroused
Reduced blood flow to genital area

Vaginal tightness:

Vaginal opening feels narrow
Difficulty with penetration
Can worsen over time if sex is avoided (tissues contract further)

Urinary Symptoms:

Urinary frequency:

Need to urinate very frequently (every 1-2 hours)
Waking multiple times at night to urinate

Urinary urgency:

Sudden, intense urge to urinate
Difficulty “holding it”
Fear of not reaching toilet in time

Urinary incontinence:

Leaking urine when coughing, sneezing, laughing, exercising (stress incontinence)
Leaking on way to toilet (urge incontinence)
Can be small amounts or larger leaks

Recurrent UTIs (urinary tract infections):

Frequent bladder infections
Burning with urination
Blood in urine
Caused by changed vaginal pH (less acidic → more susceptible to bacterial overgrowth)

Painful urination:

Burning, stinging sensation when peeing
May be from UTI or just from sensitive urethra

General Genital Symptoms:

Vulvar dryness, itching, irritation:

Vulva (external genitals) feels dry, sore
Itching (can be intense)
Burning sensation
Discomfort with tight clothing, exercise

Vaginal discharge changes:

Reduced normal discharge
Or: Increased discharge that’s watery, yellow, or malodorous (from changed pH and bacterial balance)

Vaginal bleeding:

Light bleeding or spotting after sex
From fragile tissue tearing easily

Discomfort sitting or walking:

Soreness, irritation with movement or pressure
Can affect exercise, sitting for long periods

How Common Is GSM?

Extremely common — but under-discussed and under-treated.

Prevalence:

40-50% of postmenopausal women experience moderate to severe GSM symptoms
Up to 80% have some symptoms (even if mild)
Symptoms increase with time since menopause (more common 5-10 years post-menopause than immediately after)

But Most Women Suffer in Silence:

Studies show:

Only 20-30% of women with symptoms discuss them with healthcare providers
Many too embarrassed to bring it up
Many assume “it’s just part of ageing” and nothing can be done
Many healthcare providers don’t ask about sexual or urinary symptoms

Result: Countless women suffering unnecessarily with a highly treatable condition.

Why Women Don’t Seek Treatment

If GSM is so common and treatable, why don’t more women get help?

Embarrassment:

Discussing vaginal symptoms, sexual function feels uncomfortable
Particularly with male GPs or younger healthcare providers
Many women were raised not to talk about “down there”

Assumption It’s Normal/Inevitable:

“This is just what happens when you get older”
“Menopause means the end of your sex life”
These beliefs are wrong — but widely held

Don’t Know Treatment Exists:

Many women genuinely don’t know that topical oestrogen exists or is effective
Think lubricants are the only option (they help during sex but don’t treat underlying tissue changes)

Fear of Oestrogen/HRT:

Concern about cancer risks
Don’t realize topical oestrogen is different from systemic HRT (much lower dose, minimal absorption, safer profile)

Healthcare Providers Don’t Ask:

Many GPs don’t routinely ask about sexual function or urinary symptoms in menopause reviews
Women wait to be asked rather than volunteering information
Symptoms go undiagnosed and untreated

Prioritize Other Symptoms:

Focus on hot flushes, mood, sleep in menopause discussions
Sexual and urinary symptoms feel less urgent (though equally impactful on quality of life)

Treatment: Topical Oestrogen

The gold standard, most effective treatment for GSM is topical oestrogen — oestrogen applied directly to vaginal tissues.

How It Works:

Topical oestrogen:

Applied directly to vaginal/vulvar tissues (cream, pessary, tablet, or ring)
Works locally on those tissues
Reverses the tissue changes caused by oestrogen deficiency
Restores vaginal lining thickness, elasticity, lubrication
Normalizes vaginal pH
Improves blood flow to area
Strengthens tissues

Result: Symptoms dramatically improve or resolve.

Formulations Available:

Vaginal oestrogen cream:

Cream applied with applicator into vagina
Can also be applied externally to vulva if vulvar symptoms present
Brand names: Ovestin (oestriol), Gynest (oestriol)
Dose: Typically applied nightly for 2 weeks, then 2-3x weekly maintenance

Vaginal pessaries or tablets:

Small tablet/pessary inserted into vagina (like a tampon)
Dissolves and releases oestrogen
Brand names: Vagifem (estradiol), Imvaggis (estradiol)
Dose: Typically one pessary nightly for 2 weeks, then twice weekly maintenance

Vaginal ring:

Flexible ring inserted into vagina
Releases low-dose oestrogen continuously
Brand name: Estring (estradiol)
Stays in place for 3 months, then replaced
Many women prefer this (don’t have to remember applications)

All are effective — choice depends on personal preference.

Ultra-Low Dose vs. Standard Low Dose:

Ultra-low dose:

Vagifem 10 mcg, Imvaggis 4 mcg
Extremely low dose
Minimal systemic absorption
Often sufficient for mild-moderate symptoms

Low dose:

Ovestin cream, Vagifem 25 mcg
Slightly higher dose (still very low compared to systemic HRT)
More effective for severe symptoms
Still minimal systemic absorption

Start with lowest effective dose, increase if needed.

Safety:

Topical vaginal oestrogen is extremely safe:

Minimal systemic absorption:

Very little oestrogen enters bloodstream
Works locally on tissues
Doesn’t significantly affect blood oestrogen levels
Much lower dose than systemic HRT (patches, tablets)

Does NOT increase:

Breast cancer risk (no evidence of increased risk)
VTE (blood clot) risk
Stroke risk
Cardiovascular risk

Can be used even when systemic HRT is contraindicated:

History of breast cancer (discuss with oncologist, but often permissible)
History of VTE
Cardiovascular disease
Age over 60
Time >10 years post-menopause

No time limit on use:

Can be continued indefinitely
Most women need ongoing treatment (symptoms return if stopped)
No increased risks with long-term use

Progesterone not required:

With topical vaginal oestrogen, you don’t need progesterone (even if you have a uterus)
Dose is too low to stimulate endometrium
Exception: If using high-dose oestrogen cream over large area for extended period, discuss with prescriber

How Quickly It Works:

Timeline:

Initial improvement: 2-4 weeks (tissues begin to thicken and repair)
Significant improvement: 6-12 weeks
Full effect: 3-6 months

Most women notice:

Reduced dryness within 2-3 weeks
Improved comfort during sex by 4-8 weeks
Urinary symptoms improve over 2-3 months

Important: Give it time. Tissues took years to thin; they need months to fully regenerate.

Maintenance Treatment:

Topical oestrogen is not a one-time treatment — it’s ongoing maintenance.

Typical regimen:

Loading phase: Nightly application for 2 weeks (builds up tissue health rapidly)
Maintenance phase: 2-3x weekly ongoing

If you stop treatment:

Symptoms gradually return (over weeks-months)
Tissues thin again
You’ll need to restart

Most women continue indefinitely — because stopping means symptoms recur.

Other Treatment Options

While topical oestrogen is most effective, other options exist:

Systemic HRT:

If you’re taking systemic HRT (patches, tablets, gel) for hot flushes, mood, etc.:

This provides some benefit to vaginal/urinary tissues
But often not sufficient for moderate-severe GSM
Many women on systemic HRT still need topical vaginal oestrogen as well

If you’re NOT on systemic HRT:

Topical vaginal oestrogen alone is usually sufficient for GSM
Can be used without systemic HRT

Non-Hormonal Options:

Vaginal moisturizers:

Regular (every 2-3 days) use of vaginal moisturizer
Different from lubricant (moisturizers used regularly, not just during sex)
Examples: Replens, Sylk, Yes VM
Help with dryness but don’t reverse underlying tissue changes
Useful if oestrogen contraindicated or declined

Lubricants:

Used during sexual activity
Water-based (Durex Naturals, Yes WB) or silicone-based (Überlube, Yes OB)
Help reduce friction during sex
Don’t treat underlying tissue changes
Most effective when combined with vaginal moisturizers or topical oestrogen

Vaginal laser therapy:

CO2 or erbium laser applied to vaginal tissues
Stimulates collagen production, tissue regeneration
Evidence mixed — some studies show benefit, others less impressive
Expensive (typically £1,500-3,000 for course of treatment)
Not available on NHS in most areas
May be option if oestrogen contraindicated

Vaginal DHEA:

Dehydroepiandrosterone (hormone precursor) as pessary
Converts locally to oestrogen and testosterone
Brand name: Intrarosa (not widely available in UK)
Alternative to oestrogen

Pelvic Floor Physiotherapy:

If urinary incontinence is prominent:

Pelvic floor exercises (Kegels) strengthen muscles
Pelvic floor physiotherapy can be very helpful
Often covered by NHS
Combine with topical oestrogen for best results (strong muscles need healthy tissues)

Addressing Common Concerns

“Is Topical Oestrogen Safe If I’ve Had Breast Cancer?”

This is complicated and requires individualized discussion with your oncologist.

General principles:

Topical vaginal oestrogen has minimal systemic absorption (very little enters bloodstream)
Multiple studies show no increased breast cancer recurrence risk with low-dose vaginal oestrogen
Many oncologists now permit it (particularly for severe symptoms impacting quality of life)
Some oncologists still advise against it (overly cautious approach)

If you’ve had breast cancer and are suffering with GSM:

Discuss with oncologist
Reference evidence showing safety of low-dose vaginal oestrogen
Consider non-hormonal options if oncologist very concerned (moisturizers, lubricants, laser therapy)

Don’t suffer in silence because of fear — have the conversation.

“Will My Partner ‘Absorb’ Oestrogen During Sex?”

This is a common worry — particularly men concerned about “getting oestrogen.”

The answer:

Minimal oestrogen is present in vaginal tissues (absorbed into cells)
Amount that could transfer during intercourse is miniscule
No evidence of any effects on male partners
No concern for male or female partners

If using cream (rather than pessary/tablet):

Apply at bedtime (not immediately before sex)
By morning, cream is absorbed

This is not a reason to avoid treatment.

“I Haven’t Had Sex in Years Because of Pain. Is It Too Late?”

No, it’s not too late.

Even if you’ve avoided sex for years due to pain:

Topical oestrogen can restore tissue health
Vaginal opening may have narrowed (from disuse) but can be gently stretched
Some women benefit from vaginal dilators (graduated sizes to gently expand vaginal opening over time)
Pelvic floor physiotherapy can help

Start topical oestrogen (allows tissues to heal). After 2-3 months of treatment, tissues are healthier and more able to stretch comfortably.

Take it slowly:

Don’t rush to intercourse
Start with external touching, fingers (yours or partner’s)
Progress gradually
Use lubricant during sex (even with topical oestrogen)
Communicate with partner

Many women successfully resume comfortable sex after years of avoidance — with treatment and patience.

“What If I’m Embarrassed to Ask My GP?”

Understandable — but your health and quality of life are worth overcoming embarrassment.

Strategies:

Write it down:

Write your concerns/symptoms on paper
Hand to GP at appointment
Easier than saying it aloud initially

Frame it medically:

“I’m experiencing genitourinary syndrome of menopause with dyspareunia, vaginal dryness, and urinary frequency. I’d like to discuss topical oestrogen treatment.”
Clinical language sometimes feels less embarrassing

Request female GP:

If more comfortable discussing with female healthcare provider, request this

Bring partner:

Some women feel more comfortable with partner present
Can help advocate for you

Remember:

GPs see this constantly — it’s not shocking or unusual to them
It’s a medical symptom like any other
You deserve treatment

When to Seek Specialist Care

Most GPs can prescribe topical oestrogen — this should be routine primary care.

Seek specialist (gynecology or menopause specialist) if:

GP refuses to prescribe:

Without clear contraindication
This is inappropriate — seek second opinion or specialist

Treatment not effective:

Used topical oestrogen for 3-6 months without improvement
May need higher dose, different formulation, or investigation of other causes

Unusual symptoms:

Persistent bleeding (not just light spotting after sex)
Visible lesions, sores, color changes
Severe pain not improving with treatment
These need specialist assessment to rule out other conditions

Other pelvic floor issues:

Significant prolapse (feeling of bulge or pressure in vagina)
Severe incontinence not improving with treatment
These may need gynecology assessment

What You Should Do

If You’re Experiencing GSM Symptoms:

Step 1: Recognize Symptoms

Ask yourself:

Do I have vaginal dryness, discomfort, itching?
Is sex painful or difficult?
Do I have urinary frequency, urgency, or incontinence?
Do I get frequent UTIs?
Am I post-menopausal or perimenopausal?

If YES: GSM is likely.

Step 2: Discuss with GP

Don’t wait for GP to ask — many won’t.

Be direct: “I’m experiencing vaginal dryness, painful sex, and urinary frequency. I believe this is genitourinary syndrome of menopause. I’d like to try topical vaginal oestrogen.”

If embarrassed:

Write symptoms down, hand to GP
Request female GP if more comfortable
Remember it’s a medical condition requiring treatment

Step 3: Start Treatment

Topical oestrogen:

Choose formulation (discuss options with GP)
Typical regimen: nightly for 2 weeks, then 2-3x weekly maintenance
Use consistently
Give it time (3-6 months for full effect)

Also consider:

Vaginal moisturizer (every 2-3 days)
Lubricant during sex (water or silicone-based)
These complement topical oestrogen

Step 4: Monitor Improvement

Track symptoms over 3-6 months:

Dryness improving?
Sex becoming more comfortable?
Urinary symptoms better?

If significant improvement:

Continue maintenance treatment indefinitely

If insufficient improvement:

Discuss with GP (may need higher dose, different formulation)
Consider specialist referral

Step 5: Don’t Stop Treatment

Topical oestrogen is ongoing maintenance (not a cure).

If you stop:

Symptoms gradually return
Tissues thin again

Most women continue indefinitely — no time limit, no increased risks with long-term use.

If Already on Systemic HRT But Still Have GSM Symptoms:

Common scenario:

On HRT patches/tablets for hot flushes, mood, etc.
Hot flushes controlled but still have vaginal dryness, painful sex, urinary symptoms

Systemic HRT provides some benefit to vaginal tissues but often not sufficient for moderate-severe GSM.

You can (and should) add topical vaginal oestrogen:

Safe to use both
No interaction
No contraindication
Systemic HRT addresses overall symptoms; topical oestrogen addresses local genital/urinary symptoms

Discuss with GP: “I’m on systemic HRT but still experiencing vaginal dryness and painful sex. I’d like to add topical vaginal oestrogen.”

If Concerned About Safety:

If you’re worried about using oestrogen (even topically):

Remember:

Topical vaginal oestrogen is extremely safe
Minimal systemic absorption
No evidence of increased breast cancer, VTE, stroke, or cardiovascular risk
Can be used when systemic HRT is contraindicated
No time limit on use

If you have history of breast cancer or other specific concern:

Discuss with oncologist or specialist
Review evidence
Weigh risks vs. benefits (suffering with GSM has significant impact on quality of life)

Don’t let unfounded fear prevent you from getting treatment that could dramatically improve your life.

The Impact of Untreated GSM

Why does this matter? Why not just “live with it”?

Quality of Life:

GSM profoundly impacts quality of life:

Sexual function, intimacy, relationships
Comfort in daily life (sitting, walking, exercise)
Urinary symptoms affect work, social activities, sleep
Chronic discomfort, pain
This is not trivial — it affects every aspect of life

Relationship Impact:

Sexual difficulties strain relationships:

Loss of intimacy
Partner frustration (even if understanding)
Women avoid physical affection (fear it will lead to painful sex)
Can lead to relationship breakdown

Open communication and treatment can restore intimacy — many couples report improved closeness after GSM is treated.

Mental Health:

Chronic symptoms affect mental health:

Depression, anxiety
Loss of confidence, self-esteem
Feeling “broken” or “old”
Isolation (withdrawing from activities, relationships)

Treatment can dramatically improve psychological wellbeing as well as physical symptoms.

It’s Progressive:

GSM doesn’t improve on its own — it worsens over time without treatment.

Early treatment:

More effective (less severe tissue changes to reverse)
Prevents progression
Maintains sexual function, urinary health

Delaying treatment:

Symptoms worsen
More difficult to treat (though still treatable)
Years of unnecessary suffering

The Bottom Line

Vaginal dryness, painful sex, and urinary symptoms after menopause are NOT “just part of getting older.”

They’re caused by oestrogen deficiency affecting genital and urinary tissues — a condition called Genitourinary Syndrome of Menopause (GSM).

GSM is:

Extremely common (40-50% of postmenopausal women have moderate-severe symptoms)
Progressive (worsens without treatment, doesn’t improve on its own)
Highly treatable

Topical vaginal oestrogen is:

Gold standard treatment
Highly effective (dramatically improves or resolves symptoms in most women)
Extremely safe (minimal systemic absorption, no increased cancer/cardiovascular risks)
Can be used long-term indefinitely
Can be used even when systemic HRT is contraindicated
Available as cream, pessary, tablet, or ring (choose based on preference)

Treatment timeline:

Initial improvement within 2-4 weeks
Significant improvement by 6-12 weeks
Full effect 3-6 months
Maintenance treatment ongoing (symptoms return if stopped)

Don’t suffer in silence:

These symptoms are common but under-discussed
Many women too embarrassed to seek help
Many don’t know treatment exists
You deserve treatment — this is a medical condition affecting quality of life

If experiencing symptoms:

Discuss with GP (request topical vaginal oestrogen)
Be direct and specific
Don’t accept “it’s just part of ageing” — demand evidence-based treatment
If GP won’t prescribe without good reason, seek specialist care

Your sexual health, urinary health, and comfort matter.

Treatment is available, safe, and effective.

Don’t wait years suffering unnecessarily — get help now.

Need Support?

If you’re experiencing genitourinary syndrome of menopause and need help accessing appropriate treatment, I can help.

As a registered nurse and prescriber specializing in menopause care, I provide comprehensive assessment and prescribing for GSM including topical vaginal oestrogen.

Book a consultation to discuss your symptoms and treatment options.

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