Has your vagina started to protest everything you love as you enter your 40s or 50s (sex, hot yoga, your favorite thong) with symptoms like burning, itching, dryness, and frequent UTIs? You may be one of 84 percent of women in menopause who deal with vaginal atrophy (1), the thinning and drying of the vaginal lining caused by declining estrogen levels.
“It’s a misconception that vaginal atrophy only impacts women during sex,” urologist Paul Gittens, M.D. says. Many women deal with itching and discomfort during everyday activities, too.
Vaginal atrophy is more than an annoying itch. Over time, it can make your vagina more prone to irritation and infection. But can you reverse or prevent vaginal atrophy? It’s complicated, urogynecologist Sarah St. Louis, M.D., says.
“The progression of symptoms will eventually stop,” St. Louis says. But that doesn’t mean you can ignore your symptoms or hope they disappear on their own. To get relief, you’ll need to talk to your doctor about treatments like menopause hormone therapy, physical therapy, laser, and more.
About the Experts
Sarah St. Louis, M.D., is a board-certified female pelvic medicine and reconstructive surgeon at the Orlando Health Women’s Institute Center for Urogynecology.
Paul Gittens, M.D., F.A.C.S., is a board-certified urologist specializing in female sexual medicine and menopause care at the Rockwell Centers for Sexual Medicine.
What Is Vaginal Atrophy?
Vaginal atrophy, also known as the genitourinary syndrome of menopause (GSM) or atrophic vaginitis, is caused by declining estrogen levels in perimenopause and menopause (2). The skin in your vagina and on your vulva can become dry and atrophied because estrogen stimulates collagen and elastin production—two proteins that keep skin moisturized, elastic, and healthy (3, 4). The hormone also promotes blood flow to your vagina, which supports arousal.
Vaginal atrophy can take months or years to develop, according to St. Louis. At first, you might notice less lubrication during sex, along with other symptoms like (2):
Symptoms typically begin during perimenopause and gradually progress until menopause. “Some women experience vaginal atrophy symptoms in their early to mid-40s, while others start to experience symptoms around 50,” she says.
The severity of symptoms varies from woman to woman, Gittens says. Some women experience a decrease in lubrication during sex, while others deal with multiple intense symptoms. Actress Halle Berry described vaginal atrophy as “razor blades” in her vagina.
Urinary tract atrophy
If you frequently visit urgent care to pick up an antibiotic prescription to kick recurrent urinary tract infections, GSM could be the culprit.
A drop in estrogen levels can atrophy your lower urinary tract, too, causing recurrent urinary tract infections (5). Low estrogen can also weaken your pelvic floor muscles, which can lead to urinary incontinence or retention—in other words, you may have trouble holding in your pee or emptying your bladder fully. These changes can make you more prone to a bacterial infection in your urinary tract (5).
Vulvar atrophy
GSM doesn’t just impact the internal skin of the vagina—it can also wreak havoc on your vulva (the outside part of your genitals) and other areas of the vulvovaginal area. Symptoms of vulvar atrophy include (6, 7):
Itching on the vulva
Painful sex
Skin discoloration
Loss of pubic hair
Clitoral atrophy
The clitoris plays an equally essential role—if not more—in an enjoyable sexual experience as your vagina. But, like your vagina, this all-important bundle of nerves can also fall victim to atrophy (8).
Clitoral atrophy can dampen the sensation you would typically feel during sex or masturbation, making it challenging to reach orgasm (8). If you’re one of the 36 percent of women who need clitoral stimulation to reach orgasm, atrophy can make climaxing feel impossible (9).
Some women with GSM may notice that their labia minora—the skin that extends from the clitoris around the vaginal opening—appears shriveled or less prominent. But the appearance of the labia isn’t the only thing that changes. Labia atrophy can also cause symptoms like (10):
Technically, vaginal atrophy is caused by menopause—which is irreversible. Once estrogen levels bottom out, they don’t come back naturally. But you can effectively manage GSM with the right approach.
With vaginal atrophy, “what we mean by ‘irreversible’ is that you can’t just do one treatment and expect vaginal atrophy to go away forever,” Gittens explains. “There has to be some kind of management plan to keep the vagina as healthy as possible.”
Think of treating vaginal atrophy like maintaining muscle by going to the gym, Gittens suggests. As long as you stick to your workouts, you’ll stay strong. But if you quit, you’ll lose that strength. The same applies to managing vaginal atrophy—consistent treatment is needed to keep symptoms at bay for the long haul.
Treatment for Vaginal Atrophy
Your doctor may suggest these treatments—or a combination of them—to treat vaginal atrophy symptoms and stop its progression.
Menopause hormone therapy (MHT)
Vaginal estrogen is a safe and effective way to help the lining of the vagina regain moisture and elasticity (11).
“Vaginal estrogen helps prevent infections, increases blood flow, and provides a natural production of lubrication by drawing moisture back into the cells,” Gittens explains. Vaginal estrogen comes in several forms, including:
Systemic hormone therapy, like combined estrogen and progesterone pills or testosterone injections, may not be as helpful for managing vaginal atrophy, St. Louis says (11). Systemic therapy is most helpful for vasomotor symptoms like hot flashes, anxiety, and night sweats.
“Vaginal estrogen cream is targeted local therapy for the vagina and bladder, which is why it works better for vaginal atrophy symptoms,” St. Louis says. If you’re struggling with other symptoms of perimenopause alongside vaginal atrophy, your doctor may prescribe both systemic and local HRT.
Timing is also key. Starting hormone treatment during perimenopause may prevent vaginal atrophy from developing in the first place, St. Louis says. As long as you stick with your treatment, your symptoms should remain at bay.
While the long-term risks associated with menopause hormone therapy have been debated, the latest research suggests that both systemic and topical HRT are safe to use beyond menopause to relieve symptoms.
DHEA
Vaginal estrogen may be the most popular topical treatment for atrophy, but it’s not the only option. DHEA cream, which contains a hormone that your body converts into testosterone and estrogen, can also help (12). When applied to the vagina, DHEA boosts local levels of testosterone and estrogen, which may help improve symptoms of vaginal atrophy like dryness, burning, and irritation.
A 2021 review found that 12 weeks of daily topical DHEA significantly improved atrophy symptoms compared to a placebo (12). There are no clinical trials comparing the effectiveness of vaginal estrogen and DHEA creams.
Pelvic floor physical therapy
Some doctors recommend working with a pelvic physical therapist to help with several problems that can be caused by vaginal atrophy. They can teach you how to use vaginal dilators—plastic or silicone devices that slowly stretch your vaginal tissue— to improve comfort during sex and strengthen pelvic floor muscles.
Vaginal dilators are inserted into the vagina with lubricant to stretch your muscles gently and improve elasticity. They come in several sizes, and the goal is to gradually work up to larger sizes over time (13). You can use dilators on your own at home; to get started, a physical therapist or doctor will need to guide you on how often and how long your sessions should last. Use plenty of lubricant and avoid sizing up too quickly.
You may feel relief within a few weeks, but it also could take several months—and that’s completely normal.
Other physical therapists may suggest exercises such as kegels—repeated squeezing of the muscle you use to stop the flow of urine—to encourage blood flow to your vaginal skin and to strengthen your pelvic floor (14). Strengthening your pelvic floor can improve several common GSM symptoms by reducing how often and how badly you feel you need to urinate, pain during sex, and difficulty orgasming.
You can do kegels on your own or with the support of an electric pulse machine, which helps if you have trouble stimulating the right muscles.
Moisturizers
Gittens says over-the-counter moisturizers that contain hyaluronic acid or vitamin E are effective— and often inexpensive options—for women who can’t (or don’t want to) take hormones or those seeking additional relief alongside other therapies.
Women who used a hyaluronic acid-based vaginal moisturizer experienced 84 percent relief from their GSM symptoms after 10 applications, according to a 2013 study (15) Lubricants containing hyaluronic acid may also immediately ease discomfort during sex.
Laser treatments
MonaLisa Touch, a CO2 laser treatment, can thicken vaginal tissues to alleviate atrophy symptoms. The procedure requires three initial sessions and annual maintenance, but some women notice improvement after the first session.
The MonaLisa Touch laser treatment is an option for women who can’t use hormones, like breast cancer patients, says Gittens. It can also be combined with hormone therapy for enhanced relief in severe cases.
Laser treatment for vaginal atrophy isn’t FDA-approved or covered by insurance (16). Gittens says you can expect to spend from $1800 to $3000 for the initial three sessions.
The Bottom Line
Declining estrogen levels in menopause cause vaginal atrophy, also known as genitourinary syndrome of menopause (GSM). The condition can lead to symptoms like vaginal dryness, itching, burning, and recurrent UTIs. While vaginal atrophy can’t be reversed permanently, treatments like menopause hormone therapy, physical therapy, vaginal moisturizers, laser therapy, and topical DHEA may improve symptoms. Starting menopause hormone therapy (MHT, also known as HRT) during perimenopause may reverse the atrophy that has occurred and also prevent vaginal atrophy from developing or progressing.
Rebekah Harding is a Health Writer at The Edge. She is an experienced health and lifestyle writer with both digital and print bylines in Men’s Health, Cosmopolitan, Yoga Journal, Giddy, and more.
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