Menopause: Impact on Nether Regions

Andrew Siegel MD  9/23/17

Image above by Mikael Häggström (Own work) [CC0], via Wikimedia Commons

Menopause is the cessation of estrogen production by the ovaries.  It typically occurs at about age 51-years-old, so most women can expect to live another thirty or more years following this event. Many bodily changes occur with menopause, with the urinary and genital systems undergoing sudden and, at times, dramatic changes due to the absence of estrogen stimulation.

The constellation of symptoms related to menopause used to be referred to as “atrophic vaginitis” or “vulvo-vaginal atrophy.” However, these terms were considered disparaging, hurtful and cruel, especially the words “atrophic” and “atrophy,” which imply wasting away through lack of nourishment. Also, the “-itis” designation incorrectly implied inflammation or infection. A more politically correct, medically accurate, less embarrassing and more acceptable term was proposed by the International Society for the Study of Women’s Sexual Health and the North American Menopause Society: “Genitourinary Syndrome of Menopause (GSM).”

“Genitourinary Syndrome of Menopause”–  I don’t particularly care for this term because of its length, the fact that it sounds way too clinical, and implication that menopause causes a medical “syndrome” or “disease” as opposed to a natural, physiological, age-appropriate, virtually universal situation.  Why not label the constellation of symptoms related to menopause as “menopausal symptoms and signs”?

The female hormone (estrogen)-stimulated vagina of a young adult female has a very different appearance from that of a female after menopause. The vestibule, vagina, urethra and base of the urinary bladder have abundant estrogen receptors that are no longer stimulated after menopause, resulting in diminished tissue elasticity and integrity.  Age-related changes of the vulva and vagina can lead to dry, thinned and brittle tissues with loss of vaginal length and width, lubrication potential and expansive ability. Considering that nature’s ultimate purpose of sex is for reproduction, perhaps it is not surprising that when the body is no longer capable of producing offspring, changes occur that affect the anatomy and function of the genital organs.

Symptoms and Signs of Menopause

General

• Hot flashes
• Night sweats
• Sleep disturbances
• Mood changes and fluctuations

Vulva

• Thinning/loss of elasticity of labia and underlying fatty tissues
• Diminished tissue sensitivity
• Paler, thinner and more fragile vulvar skin
• Increase in vulvar skin issues and vulvar pain, burning, itching and irritation

 Vagina

• Thinning of the vaginal wall
• Loss of vaginal ruffles and ridges
• Shortened vaginal dimensions
• Looseness of  the vaginal opening
• Increased vaginal pH (less acid environment)
• Increased vaginal colonization by colon bacteria and more frequent vaginal infections

 Sexual

• Diminished sex drive
• Vaginal dryness
• Diminished arousal
• Diminished lubrication
• Diminished ability to achieve orgasm
• Tendency for painful sexual intercourse

 Urinary 

• Thinning of the urethral wall and tissues adjacent to the urethra
• Urinary infections: Before menopause, healthy bacteria reside in the vagina; after menopause, the vaginal bacterial ecosystem changes to colon bacteria, which can predispose to infections.
• Overactive bladder symptoms: urinary urgency, frequency, urgency incontinence
• Stress urinary incontinence (urinary leakage with sneezing, coughing, exercise and exertion)
• Urethral caruncles (benign fleshy outgrowths at the urethral opening)

What to do?

If the symptoms and signs of menopause are not bothersome, nothing need be done. In fact, many women relish not having menstrual periods and tolerate menopause uneventfully.  However, if one’s quality of life is adversely affected, consideration can be made for hormone replacement therapy, particularly if the menopausal symptoms are disruptive and debilitating.

Hormone Replacement

Systemic hormone therapy is available in the form of pills, skin patches, sprays, creams and gels. It can be effective in managing bothersome menopausal symptoms when used for the short-term. Estrogen alone is used in women who have had a hysterectomy, whereas estrogen and progesterone in those who have a uterus. The potential side effects of systemic therapy include an increased risk for heart disease, breast cancer and stroke.

Vaginal hormone therapy is available in creams, rings and tablets. The advantage of  locally-applied estrogen is that it can help manage menopausal pelvic floor issues with minimal absorption into the body and minimal potential systemic effects, as would be expected from oral hormone replacement therapy. It can be helpful for painful intercourse, overactive bladder, stress urinary incontinence, pelvic organ prolapse and recurrent urinary tract infections. Additionally, because estrogen restores suppleness to the vaginal tissues, it can be very useful both before and after vaginal surgical procedures (most commonly for stress urinary incontinence and pelvic organ prolapse).

Note: I commonly prescribe topical estrogen therapy, typically a small dab applied vaginally prior to sleep three times weekly.  It has proven helpful and effective in a variety of circumstances.

Kegel Exercises

Clinical studies have demonstrated that Kegel exercises can effectively improve certain domains of sexual function, particularly arousal, orgasm and satisfaction. This is not surprising given that the pelvic floor muscles are essential to arousal and orgasm, with weakness in these muscles resulting in reduced pelvic and vaginal blood flow and lack of adequate lubrication, painful intercourse and difficulty achieving climax.  Furthermore, Kegel exercises can be effective in the management of overactive bladder, stress urinary incontinence, and pelvic organ prolapse.

Stay Sexually Active: Use it or Lose it

Sexual intercourse can be painful after menopause because of anatomical and functional changes that result in difficulty in accommodating a penis.  This is particularly the case if one has not been sexually active on a regular basis.  Sexual activity is vital for maintaining the ability to have ongoing satisfactory sexual intercourse. Vaginal penetration increases pelvic and vaginal blood flow, optimizing lubrication and elasticity, while orgasms tone and strengthen the pelvic floor muscles that support vaginal function.  Lubricants can be used for women experiencing vaginal dryness and painful intercourse.

Lifestyle Modification

Pursuing a healthy lifestyle can provide some degree of relief from menopausal symptoms. These measures include a maintaining a healthy weight, a diet emphasizing plant-based proteins, fruits and vegetables, moderate exercise, sufficient quantity and quality of sleep, caffeine reduction, tobacco cessation and alcohol in moderation.

Bottom Line: Menopause is an inevitable part of the aging process with the absence of menstrual periods a welcome change for many women.  However, the cessation of estrogen production can cause a host of symptoms and consequences, particularly affecting the urinary and genital organs.  If symptoms are bothersome, there are numerous means by which to improve them. 

Wishing you the best of health,

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Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

• Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health
• Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health
• Amazon page
• Co-creator of the PelvicRx male pelvic floor muscle training DVD

 

Tags: Andrew Siegel MD, hormone replacement therapy, menopause, painful sex, symptoms of menopause, urinary incontinence, vaginal dryness