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Vaginal health and sexual fulfillment

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Senior-Couple-in-Sweaters-on-the-SeashoreThe transition for most women into menopause is characterized by a complex interplay of hormonal changes, most notably involving estrogen and progesterone. Understanding these transitions is vital because of their profound impact on a woman’s vaginal health, sex life, and overall health and well-being. Sexual well-being following the transition into menopause may seem out of reach for many women. Studies have shown that women place a high value on sexual intimacy in their relationships. Depending upon the individual circumstances, the physical changes at menopause can add stress to a relationship. They can develop into chronic sexual symptoms involving disruptions to sexual desire, arousal, orgasm, and the experience of pain during sexual activity. This distress is the hallmark of female sexual dysfunction (FSD). The International Menopause Society is working to increase awareness of FSD and to provide a framework for practitioners to address sexual medicine concerns. The publication “Recommendations on women’s midlife health and menopause hormone therapy” reviews the care process for female sexual well-being following menopause, identifies clinical signs and symptoms, and ultimately determines the best available biopsychosocial therapies. Unfortunately, there is still a prevalent belief that such menopausal changes are a normal and inevitable part of aging. However, it is essential to realize that there is reason to challenge these outdated views and understand that many simple and affordable solutions directly address these problems.

Understanding the Impact of Menopause on Vaginal Health and Sexual Fulfillment

Menopause is a natural biological process in women’s lives as they mature. It brings a series of changes, both emotional and physical. While much attention is given to some of the more common symptoms, like hot flashes or mood swings, there is less conversation about the changes in the vagina and how they can affect a woman’s sexual health. Understanding these changes can lead to more comfort and satisfaction for mature women with stable relationships and a keen interest in overall well-being.

What Happens in the Vagina During the Menopausal Shift?

Menopause marks the end of a woman’s reproductive years, and with the decrease in female hormone production, various changes inside and around the vagina occur. The most significant are:
  • Vaginal dryness is one of the most common symptoms, affecting around 50-60% of menopausal women. When hormone levels are high, they help keep vaginal tissues moist and elastic. Women may experience dryness with their decline, leading to discomfort – especially during sexual activity.
  • Vaginal atrophy (also known as genitourinary syndrome of menopause – GSM.) It involves the thinning and inflammation of the vaginal walls. This condition can result in pain during intercourse and urinary distress.
  • A healthy, pre-menopausal vagina typically maintains an acidic pH balance, which creates a protective barrier against infections. Post-menopause, the pH may become more alkaline, increasing susceptibility to urinary tract infections (UTIs) and other issues.
Hormonal changes can also lead to a decrease in sexual desire. However, it’s essential to recognize that other factors like relationship changes, stress, or other medical conditions can also contribute to this. In addition to the physical changes that accompany menopause, it’s crucial to acknowledge the psychological aspect of this transition as well.

Strategies for Maintaining Vaginal Health

Understanding the way that the transition into menopause produces a cascade of physical changes allows for proactive measures to maintain vaginal health and sexual fulfillment:
  • Over-the-counter lubricants and moisturizers can help alleviate dryness, making sexual activity more comfortable. There are products specifically designed for vaginal use. Among the most highly recommended are Vagifem (estradiol) vaginal suppositories, which deliver a natural form of estrogen. This medication can treat menopause symptoms and reduce urgency or irritation during urination. As an OTC medication, it does not require a prescription.
  • In many cases, especially in the early years of menopause, women may benefit from Hormonal Replacement Therapy (HRT), which can help alleviate symptoms and restore vaginal health. There are no cures for GSM, but by restoring estrogen levels with safe medications, it can be possible to reduce the symptoms substantially. Consulting with a healthcare provider is essential, as HRT may not be suitable for everyone. Combined HRT (including progesterone with estrogen) is usually required for women with an intact womb to reduce the risk of hyperplasia and adenocarcinoma (cancer) of the endometrium.
  • Localized estrogen therapy is a specialized form of HRT that can effectively treat vaginal atrophy. One of the best examples is Premarin Vaginal Cream (conjugated estrogens,) which provides a targeted delivery route directly onto the tissues in and around the vagina. Unlike oral HRT, which circulates throughout the body, vaginal creams deliver higher estrogen concentrations onto vaginal tissues, effectively addressing the symptoms of vaginal atrophy without a significant impact on the rest of the body.
  • Regular sexual activity helps maintain blood flow to the vaginal tissues, keeping them healthy and elastic.
  • Healthy lifestyle choices, like drinking water regularly, maintaining a balanced diet, and engaging in regular exercise, all contribute to overall well-being and support sexual health.
  • Discussing sex openly with a partner, a willingness to talk about the changes that menopause brings, and finding new ways to accommodate intimacy can strengthen relationships and increase satisfaction.
  • Finding a healthcare provider that specializes in menopause can provide individualized care and treatment options, including physical therapy when needed, tailored for sexual health.

Learn about Female Sexual Interest/Arousal Disorder (FSIAD)

Female sexual dysfunction is a recognized condition listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Aside from the more general problems that may afflict sexually mature females of any age, there is a specific emphasis that affects women as they pass through premenopause and enter the final phase of full menopause. The importance of this stems from the growing length of time women spend on average in menopause. Thanks to increases in life expectancy, women can now confidently expect to live into their eighties, which means that the majority of women who enjoyed around 25 years of fertility and childbearing (and that figure hasn’t changed much, if at all) will go on to spend 35 or more years in menopause.  FSAID has now become a matter of deep concern and interest.

Understanding the Functions and Impact of Estrogen, Progesterone, and Testosterone

  • Beyond simply regulating the menstrual cycle, estrogen plays a vital role in many bodily functions, including maintaining bone density, controlling cholesterol levels, and keeping the skin elastic. Its decline affects not only reproductive health but overall systemic well-being.
  • While the primary role of progesterone is in the reproductive system, which is essential for preparing the uterine lining for a potential pregnancy, progesterone also has a calming effect on the brain and contributes to mood stabilization. Its decline may contribute to mood swings during perimenopause.
  • Testosterone is generally considered a male hormone (androgen) but plays a role in female reproductive and sexual function. As women age through their reproductive years, there is an overall decrease in levels of androgen, which play an essential role in sexual motivation in women. Consequently, older women may experience hypoactive sexual desire disorder (HSDD), which reflects changes in sexual arousal and desire, the ability to reach orgasm, pain from intercourse, and the absence of desire for sexual activity.

Hormonal Changes in the Transition into Menopause

Perimenopause often begins in the late forties but can start earlier, marked by a gradual decrease in estrogen and progesterone levels:
  • Estrogen is primarily responsible for regulating the menstrual cycle. Levels can fluctuate widely during perimenopause, and this inconsistency can lead to irregular periods and other symptoms like hot flashes.
  • As ovulation becomes less regular, the production of progesterone also decreases.
  • In many cases, perimenopause presents the most marked symptoms.
  • Menopause is defined as the absence of menstrual periods for 12 consecutive months.
  • With the decline in estrogen production comes the most characteristic symptoms of menopause, including vaginal dryness and mood changes.
  • Progesterone levels drop even more steeply since the hormone is no longer needed to prepare the uterus for the implantation of a fetus.
Menopause occurs twelve months after the final menstrual period and continues for the rest of a woman’s life.

The Magnitude and Timeline of Estrogen and Progesterone Decline


In early perimenopause, estrogen levels can fluctuate widely with increases and decreases, ranging from 10-30% above and below average levels. In late perimenopause, estrogen levels drop to around 35-60% below normal levels in the years just preceding menopause. Finally, estrogen levels may drop dramatically to approximately 40-60% below premenopausal levels around the last menstrual period. In menopausal women, estrogen levels can be even 90% below what was expected in fertile years.


Throughout the years of perimenopause, progesterone levels decline as ovulation becomes irregular. They may drop by approximately 25-50% below average levels during the reproductive years. Finally, a sharp drop to near zero occurs in sync with the cessation of ovulation.


During her years of fertility, generally from around the mid-twenties, a woman’s testosterone levels decline steadily. Still, they level off once menopause is reached and may even start to rise slowly.

The Timeline

Perimenopause typically begins in the mid to late forties but can start as early as the late thirties. It can last anywhere from four to as long as ten years. In the US, menopause, on average, sets in at the age of 51, according to the National Institute on Aging, and continues for the rest of a woman’s life.


Which vaginal lubricants work best to relieve dryness and discomfort?

Water-based personal vaginal lubricants that include estradiol/estrogen can improve dyspareunia and relieve vaginal dryness and improve vaginal health. They can also increase sexual satisfaction in menopausal women. The lubricants have also been found not to alter the vaginal microbiome, so the risk of UTI and other infections is not elevated.

What is the average timeline for menopause?

There is no such thing as a standard duration for menopause. It would depend on a woman’s genes, her prior lifestyle factors such as smoking and recreational drugs or alcohol consumption, general health and many other unique influences. Some women barely notice the transition beyond the cessation of periods, and others suffer from some or all of the common symptoms to greater or lesser degrees, for the rest of their lives.

How long does it take to see results from the estradiol cream in Vagifem?

Topical lubricants and moisturizers such as Vagifem, which contains estrogen cream, address the root cause of vaginal atrophy, whereas other OTC creams only minimize them. While restoring the vaginal, vulvar and urethral tissues to their premenopausal state will start gradually, the total improvement should be evidenced by four to twelve weeks.
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