What is vaginal atrophy and what are the symptoms?

Vaginal atrophy, more commonly known as vaginal dryness and whose official worldwide term is GSM (genitourinary syndrome of menopause), is a set of symptoms that can affect the whole urogenital area. This is the inside of the vagina, the vulva (external), bladder, urethra and the whole pelvic floor area. As we age and head towards perimenopause and then post menopause, the lack of oestrogen and testosterone affects women from the top of their head to the tip of their toes and everything in between.

The problems GSM can cause vary from mild to severe and anything in between and include dryness, watery discharge, burning, soreness, itching, urinary tract infections, painful sex and smear tests, bleeding with penetration, stress and urge urinary incontinence, multiple night times toilet trips, thinning skin including splitting of old episiotomy scars, being unable to wear tight fitting garments and being unable to sit down or exercise.

Many women in surgical menopause report recurrent Urinary Tract Infections after surgery. Why is this and what would you recommend to help?

Women who go into surgical menopause can be hit like a freight train at speed with symptoms appearing a few hours after surgery in some cases and weeks or months later in others.
Whilst it is common to get UTIs at any age, the bladder loves oestrogen. So when it’s taken away from us both naturally or suddenly, the subsequent drying out of the vagina and bladder allows UTIs to take hold more readily as the area has become thinner and dryer. Localised oestrogen along with a good quality vaginal moisturiser into the vagina can often really help.

How would you differentiate between thrush and vaginal atrophy?

This is the million dollar question as so many women and medics assume every itch or discharge leads to thrush – this is simply not the case! With menopause, the pH levels in the vagina can make us more prone to thrush as the environment is no longer as healthy as it was.
But, you should never self-treat for thrush and always insist on a swab before treating as so often it’s not thrush. However, if you’re getting repeated thrush confirmed by swabs when you have never done so before, then this is highly likely due to menopause. In these cases, local oestrogen should be considered.

Vaginal dryness is a symptom of menopause. What would you recommend to ease this?

There are non-hormonal or hormonal products available – often a combination of both is what works best. Oestrogen products available are pessaries, creams and rings – all of which are available on the NHS. As for vaginal moisturiser, there is rather a huge choice! Some are much better than others and you’ll need to do your research, but remember: if it smells of a rose garden then it’s a no!

Is it okay to take local oestrogen alongside systemic HRT?

Yes, it is as per the menopause NICE guidelines. In fact, about 20% of women with GSM need to take both.

Is it common to become sensitive/have reactions to products regularly used before surgical menopause? For example, body wash and washing detergent.

The drop in hormones – which is surgical menopause can feel like suddenly falling off a cliff edge – means that we can suddenly become sensitive to lubes, washing powders and what we used to be able to use to wash our vulva with as well as; however, we shouldn’t be using these products anyway whatever our age as the vulva is a very sensitive area.

Is it okay to take local oestrogen if you have or have had cancer?

Local oestrogen is considered “safe” to use; however, it’s a discussion that brings different opinions across the medical profession and this needs to be discussed with your oncologist. Do your own research and, for a non-biased, informative view on the hot potato that is oestrogen and breast cancer, I recommend a book called Oestrogen matters by Avrum Bluming. Ultimately, it’s about informed choice and quality of life.

How often should you use local oestrogen?

There is no amount set in stone and each woman is different. It can vary from as little as twice a week to as much as 7 times a week – it all depends on how bad your symptoms are and the knowledge of your HCP. That said, many find a mid-way point of 4-5 times a week.

How often should we moisturise our vulvas and what moisturisers do you recommend?

Again, there is no set amount … but due to lack of oestrogen as we age – and just like our face – our vulvas also dry. We can moisturise as much as required – we are all different and for some ladies this means moisturising 1-2 times a day whilst others may need to moisturise after each toilet visit. There are many products available and the YES products, SYLK, SUTIL and Olive and bee are considered good brands. But, again, we are all different and it’s trial and error!

Vaginal Atrophy can really impact intimacy, especially penetrative sex. Lubricants can make things more comfortable. Which ones would you recommend and why?

The products that I suggested for external use for moisturising of the vulva (the external area) can all be used internally for penetration and intimacy. If condoms are being used then obviously you need to check which ones can and can’t be used with them.

Is it common to experience Bacterial Vaginosis after surgery?

Due to the drop in oestrogen, the pH levels of the vagina change which can encourage BV and thrush. Certain vaginal moisturisers can help along with local oestrogen.

Any other important things to remember?

It’s very important women don’t self-treat any vulva or vaginal problems and it’s also very important that we examine our vulva every month. Anything that lasts longer than a month needs checking by a doctor – and every itch most definitely does not mean thrush or BV!