Vaginal Dryness and Vulvar Health in Menopause

The most common symptoms of hot flushes and night sweats are often associated with menopause – and then there are some symptoms that are way less talked about. Changes to the vagina and vulva are a far more quiet topic that deserves more awareness and attention. Asking questions like why and how does this happen, as well as what options are available to support are super valuable for us as women.

Medically, this cluster of symptoms is referred to as Genitourinary Syndrome of Menopause, or GSM. It's a newer, more accurate term (introduced in 2014) that replaced older labels like "vaginal atrophy" because the changes don't stop at the vagina. They affect the vulva, urethra and bladder at times also.  

How Common Is it?

GSM is extremely common, yet studies estimate wildly different numbers - anywhere from 13% to 87% of postmenopausal women report at least one symptom, depending on how the research is done and what's being measured. A more realistic middle-ground estimate, based on available data, suggests that 40–60% of postmenopausal women experience some degree of GSM and other analyses put the figure as high as 50–70% for women who are symptomatic to at least some extent.

Through my research, a few more numbers worth mentioning here:

• Vaginal dryness is the single most reported symptom, showing up in anywhere from 47% to 100% of affected women depending on the study population.

• Pain during sex (dyspareunia) affects roughly 20–78% of women with GSM.

• Urinary symptoms - urgency, frequent UTIs, discomfort urinating - occur in 23–50% of cases, since the urethra and bladder are just as estrogen-sensitive as vaginal tissue.

• A large community study in Beijing involving nearly 2,700 women found vulvovaginal atrophy in about 35% of participants, with the odds rising sharply with age: women 55–64 were roughly 8.6 times more likely to have it than younger participants.

  
  

And yet, only about half of women with these symptoms ever bring them up with a doctor — and of those who do, most say their clinician didn't raise the topic first. GSM is also different from hot flashes in an important way: while vasomotor symptoms often fade over time, GSM tends to be progressive and doesn't resolve on its own. Without some form of treatment, it commonly gets worse, not better.

What's Actually Happening in the Body

Oestrogen keeps vaginal and vulvar tissue thick, elastic, well-lubricated and rich in blood flow. It also maintains the vagina's naturally acidic environment, which protects against infection. When estrogen production changes after menopause, several things can happen at once:

• The vaginal walls can become thinner, less elastic and more fragile

• Natural lubrication can decrease

• Vaginal pH can rise, making the area more prone to irritation and infection

• The vulva can lose fullness and become more sensitive, itchy or easily irritated

• Blood flow to the area decreases, which can affect arousal and sensation

• The urethra and bladder lining thin as well, contributing to urinary urgency and recurrent UTIs

  
  

None of this reflects poor hygiene, poor health or "letting yourself go" - it's a direct, physiological consequence of hormonal change and it's just as real as a hot flush.

However, again, let’s not blame the hormones!

As always, I will preface this by saying that we create the environment within which the hormones can do what they do or not. We set the body up for all that it experiences. This is not a blame game or excuse to give yourself a hard time. But it is worth asking some questions, being reflective and being curious about how we have arrived at menopause. Just like we arrive every night to sleep, we can reflect on the impact of how we have lived that day that either supports the quality of sleep or makes it difficult to settle.

So, how have we arrived at this particular cycle of menopause and what impact might that have had on the body. The changes in hormones are not a design fault – they are part of the design of the body. The way we experience it, is very simply, a communication from the body.

So let’s keep all of this in mind as we explore more in upcoming articles, looking at what women actually experience and what treatment and support is available?

References

American Urological Association / SUFU / AUGS Guideline on GSM (2025) - https://www.auanet.org/guidelines-and-quality/guidelines/genitourinary-syndrome-of-menopause

Genitourinary syndrome of menopause: a systematic review on prevalence and treatment, PubMed (2021) - https://pubmed.ncbi.nlm.nih.gov/33739315/

Investigation on prevalence and risk factors associated with GSM in middle-aged and older women in Beijing - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9801667/

GSM: recommendations from the Fifth International Consultation on Sexual Medicine (ICSM 2024) - https://academic.oup.com/smr/article/14/1/qeaf055/8261468

Genitourinary syndrome of menopause, PMC/NIH overview - https://pmc.ncbi.nlm.nih.gov/articles/PMC12770846/

The Genitourinary Syndrome of Menopause: An Overview of Recent Data, PMC - https://pmc.ncbi.nlm.nih.gov/articles/PMC7212735/