Menopause is a natural biological process that marks the end of a woman’s reproductive years, typically occurring in her late 40s or early 50s. One of the most common and often challenging symptoms associated with menopause is vaginal dryness, a condition that can significantly impact a woman’s quality of life and intimate relationships. Also, many women experience mental health issues.
INTIMINA‘s gynaecologist, Dr. Susanna Unsworth, shares her valuable insights, practical advice, and evidence-based solutions to empower women going through menopause (and perimenopause) to embrace this transition confidently and comfortably.
Vaginal dryness – an important indicator of perimenopause and menopause
Studies suggest at least 50% of women going through their menopause transition will experience vaginal symptoms, and dryness tends to be the first symptom that occurs with the loss of hormones, leading to vaginal atrophic changes.
I suspect that figure is much higher, as it is a symptom many women put up with without seeking help. In my clinical practice, I always ask specifically about these symptoms to allow women to talk about them – from my own experience; I would say at least 80% of the women I see experience some degree of vaginal symptoms.
Dryness, itching, burning, increased discharge, urinary symptoms and painful sex are all potential symptoms. We now refer to this collection of symptoms as genitourinary syndrome of menopause.
Post-menopausal women, particularly older women, will often struggle with recurrent urinary tract infections due to atrophic vaginal changes related to hormone loss. These can often be misdiagnosed as urological problems.
What can help with vaginal dryness?
The loss of hormones associated with menopause is a natural process which cannot be prevented. However, that does not mean you must endure these symptoms if they affect your quality of life.
Some things can make things worse, so I generally advise avoiding perfumed products, choosing intimate health products that are pH balanced, and avoiding any internal vaginal douching. You may also want to consider the material your underwear is made of, avoiding synthetic materials. It can also be helpful to avoid spending too long doing activities that put a lot of pressure on the vulva – such as horse riding or cycling for very long periods of time (and ensuring good support/padding if you do).
Vaginal moisturisers and lubricants can be beneficial, ensuring the products used are specifically designed for vaginal use. Those that contain hyaluronic acid can be particularly helpful. Some women also find natural oils, such as coconut oil, useful.
However, the most effective treatments available are hormonal. Most consist of a topical form of oestrogen. These are delivered into the vagina as a small tablet, pessary, cream, gel or ring. The tablet form is now available to buy over the counter.
These are very effective at treating vaginal dryness and atrophy symptoms and are considered safe for most women to use as they do not cause any increase in oestrogen levels in the bloodstream. They can even be used for many women after breast cancer. However, this should always be discussed with your doctor first (the only situation where there may be concern is in women who are also using medications called aromatase inhibitors as part of their breast cancer treatment). There is another hormone pessary which contains dehydroepiandrosterone (DHEA) – this is also effective and may be a potential option for women who are using aromatase inhibitors.
To help with discomfort or pain during sex, I would advise regular use of vaginal moisturisers, with adequate lubricant used during sex. But ultimately, I would also recommend the use of vaginal hormonal treatment. It may take a little time for the symptoms to improve, so it is also essential to talk to your partner about it and avoid penetrative sex until things feel comfortable.
Pain during sex can lead to longer-term issues, such as vaginismus, so it is best to try and tackle it before other issues arise and enjoy sex in other ways whilst things improve.
Impacts of menopause on mental health
Hormonal changes definitely impact mental health. We see it frequently in women who notice mood changes throughout their normal menstrual cycle, sometimes with extreme consequences (such as PMDD). It is often due to hormonal fluctuations/changes in levels that can be a trigger. This can be why women often struggle with mood changes in perimenopause, as there is a lot of hormonal fluctuation.
The symptoms I see most commonly are low mood and anxiety. This can often occur suddenly, having never previously struggled with mental health issues. Cognitive changes are also commonly reported, with the classical ‘brain fog’ description. All of these can be significant, especially in the workplace.
There are conflicting opinions on the role of hormone therapy in managing these symptoms. Data has shown benefits in mood, and HRT is recommended over antidepressant medications when treating mood changes related to menopause. The effect on anxiety is less clear, although, in my practice, I often see improvements in this too.
The impact on cognitive function is more complex – evidence suggests improvement when HRT is used in younger women, particularly those who experience early menopause. However, the evidence is less clear when used in older women, with some data suggesting reduced cognitive function when HRT is introduced later after menopause has already occurred. More studies are definitely needed in this area.
Advice on mental health treatments
As with all elements of menopause care, I try to take an individualised holistic approach. It is important to look at social issues and lifestyle. Many factors influence mental health, and it is crucial to address them. Otherwise, other treatment options are unlikely to help.
I always encourage non-medical options – looking at diet and exercise. Still, psychological treatment options such as cognitive behavioural therapy can also be very helpful.
HRT also has a significant role in my treatment approach. I would not necessarily rush to use it solely for someone experiencing anxiety or depression. Still, it is rare for that to be the only presenting symptom of menopause. The combination of other symptoms (such as hot flushes, joint pain, vaginal issues, and changing periods) would all hint towards menopausal hormonal changes, and these symptoms will generally improve with the appropriate HRT treatment.
Antidepressants should not be offered as a first-line treatment for mood and anxiety related to menopause, but adding an antidepressant further down the line may be helpful for some women.
How to lead a healthy and fulfilled life
Menopause is definitely not ‘the end’. For some women, it can feel like ‘the beginning’ – a freedom from the constraints of the hormonal rollercoaster linked to the menstrual cycle. It is important to stress that many women can experience a very positive menopause transition. However, women do need to be supported through it – this might be support from family and friends, colleagues in the workplace, employers, and medical professionals offering appropriate treatment for when the symptoms impact their quality of life.
Every woman’s experience will be different, and many options are available to help. It saddens me when I hear women being told to just ‘get on with it’ – yes, it is a natural process and part of life, but that does not mean women must suffer in silence. The proper education, support and treatments are available, and if women are given access to these, I believe all women can thrive through this transition and come out stronger on the other side.
In conclusion, it is essential to demystify menopause and understand how to address the discomforts it brings to many women, ultimately promoting better health and well-being for women in this stage of life.