Vaginal Health During Menopause

By Dr Hazel Batten, Integrative GP at Remede Wellness Medicine

What happens to the vagina in menopause?

Genitourinary syndrome of menopause is the term used to describe what happens to the vaginal tissue during menopause. Menopause is the time when the ovaries stop producing oestrogen. Oestrogen is an essential hormone in maintaining the health of the vagina. Usually, the condition begins when the vagina has been without oestrogen for a period of time, so you might not notice these symptoms straight away. When there is a loss of oestrogen to this tissue, there is a decrease in blood flow, there is less collagen and elastin and there is less lubrication. The tissues become very fragile.

What are the symptoms?

After menopause there may be vaginal dryness and discomfort; frequency and incontinence of urine, due to a decrease in strength of the pelvic floor muscles and tearing of the skin of the vagina leading to pain or light bleeding. A normal pre-menopausal vagina is naturally acidic, but after menopause it may switch to being more alkaline. This change can increase susceptibility to urinary tract infections and vaginitis (pain). The loss of fatty tissue can also mean that the labia majora and clitoral hood may contract, which can expose sensitive areas and cause friction/chafing to the tissue.

Management of symptoms

• Wear cotton underwear
• Avoid use of feminine hygiene sprays and douching. Avoid pads, tampons and toilet paper which are scented.
• Avoid shaving or waxing the genital area, particularly if irritation is present.
• Use plain water only to wash the vaginal area. Avoid the use of soap, liquid soap, bubble bath and shower gels and use soap alternatives.
• Use a vaginal lubricant or moisturiser for sexual activity.
• Stop smoking; as this can cause microvascular damage and exacerbate the decrease in blood flow to the vagina

Non-prescription treatments:

• Cool washes with a dilute solution of bicarbonate of soda (1/2 teaspoon in 1L of water) or compresses for itching and mild discomfort.
• Polycarbophil/nonhormonal based vaginal moisturisers (Replens®) can plump up cells in the vagina, reduce vaginal symptoms and restore vaginal pH.
• Water or silicone based vaginal lubricants may decrease pain during intercourse.
• Use natural oil lubricants; coconut, olive, sweet almond or avocado oil
• Vitamin E, either orally or topically, can reduce vaginal symptoms
• Pelvic floor exercises may help urinary symptoms

Locally acting Prescription treatments:

Vaginal oestrogen:

How does it work?

Estrogen causes the lining of your vagina (i.e. the epithelium) to thicken, making the tissue stronger, less fragile, and more elastic. It can also strengthen your pelvic floor muscles, helping improve urinary symptoms. In addition, estrogen seems to increase glycogen—a sugar that feeds healthy bacteria in your vagina, particularly Lactobacillus. This leads to positive changes in your vaginal microbiome, helping protect against urinary tract infections.

• Vaginal oestrogen is effective only while it is being used. In some cases, it may be preferable to start at a reduced dose in order to minimise initial stinging/burning.
• There are different types of vaginal oestrogens available:
  • Oestradiol: Vagifem® Low pessary 10mcg/dose
  • Oestriol: Ovestin cream, 1 mg/g (0.1%) 500mcg/dose or Ovestin Ovula pessary 500mcg/dose

What are the advantages?

• There is minimal systemic absorption
• They are safe if you have a history of breast cancer. It is thought that oestriol is slightly superior as the metabolic clearance of oestriol is more rapid and systemic absorption lower.  However, there are no clinical outcome data to support superior safety or efficacy of one type of vaginal oestrogen over another in women with breast cancer.
• Vaginal oestrogen is PBS listed

What are the disadvantages?

• They may cause irritation
• Increased risk of thrush/yeast infections
• They may cause breast pain or vaginal itching/bleeding on initiation of treatment

Vaginal DHEA:

• It has long been known in the integrative medicine world that DHEA has lots of benefits for the body. However, there were no DHEA products on the market that were approved by the Therapeutic Goods Association. This changed in June 2023, when Intrarosa became available. Each Intrarosa pessary contains 6.5 mg of prasterone, a synthetic form of dehydroepiandrosterone (DHEA).

How does it work?

DHEA is a steroid hormone precursor that can be converted into estrogens or androgens. The DHEA is embedded in a waxy tablet that is inserted into the vagina each night, where it gets absorbed through the skin. It then gets converted to oestrogen or androgens, depending on what the body needs.

What are the advantages?

• There is minimal systemic absorption
• The waxes to make the pessaries are less likely to cause allergies
• As well as supporting genitourinary symptoms, it has an added benefit of helping to improve libido, sexual function and pain on intercourse

What are the disadvantages?

• Intrarosa needs to be used nightly to get the benefits
• It can increase vaginal discharge (however, this can be a advantage as it helps with lubrication)
• It is still not recommended for breast cancer survivors
• It is not PBS subsidised; the recommended retail price is $39.99 for a 28-day supply

Due to the specialist and popular nature of integrative medicine, there is often a lack of availability of appointments. Therefore, Dr Hazel requires you to maintain a relationship with your regular GP for urgent and acute health needs. Should you wish to book a consult with Dr Hazel, we encourage you to book a Collaborative Care Consult which includes Dr Hazel as your Integrative GP and an experienced Naturopathic Medicine Practitioner. Please contact the Clinic on 9286 1166 to book this appointment.