by Diana Arundell
Discussions around menopause are usually more focused on hot flushes, weight gain, fatigue and mood disturbance. These are common areas of issue with menopausal women and another area that is often neglected to be spoken about or is often made fun of is the menopausal vagina.
It’s suggested approximately 50% of women experiencing vaginal issues related to menopause don’t report/discuss it with their health professional due to embarrassment. Considering that vaginal issues around menopause can significantly affect quality of life, and quality of social and sexual relationships, it’s imperative that women feel secure and supported discussing these issues.
Unless medically induced or premature, most women will experience menopausal changes between 45-55years of age. The signs and symptoms of the menopausal vagina and urinary tract has been classified into the genitourinary syndrome of menopause (GSM) so it’s inclusive of the effects of low estrogen on the vagina, pelvic floor, urinary system, and sexual function. Menopause is characterised by a reduction in circulating estrogen and as there are large numbers of estrogen receptor cells located in the female genitourinary system, it’s no surprise that low estrogen levels lead to anatomical changes in the vagina and associated areas.
As estrogen levels decline, the following may be experienced by some (not necessarily all) women: weakening of the pelvic floor, prolapse/incontinence, narrowing of the vagina and loss of fullness of the vulva, loss of clitoral stimulation, reduced elasticity, hypersensitivity or decreased feeling, discharge. These signs and symptoms can lead to pain, infection and a decline in function. Some women simply feel slight atrophy and dryness whereas for other women the dryness can be so severe that it becomes painful to have sex, to walk and even wear certain clothing.
The vagina is muscular and as with all muscles, exercise is important along side good blood flow and vaginal pH is also of significance when considering the health of the menopausal vagina. Healthy vagina pH is 3.6-4.5 and above that range can be indicative of bacterial infection. Menopause is characterised by high levels of follicle stimulating hormone (FSH) in the blood as the body is trying to increase estrogen levels and high FSH levels are linked to a higher vaginal pH environment. Vaginal pH is affected by hormones, hygiene, menstrual flow, sex, obesity, emotions and smoking – yes tobacco metabolites have been identified in cervical fluid! The vaginal pH is significant as it affects the balance of the vaginal micro-biome. PH strips can be used to check vaginal pH as long as the pH strip reference range relates to vaginal pH reference ranges.
The micro-biome of the gastrointestinal tract has received a lot of publicity recently and it’s understood that good diversity of gut micro-biome is associated with better gut health. The micro-biome of the vagina is different as a lower diversity is more desirable with a preferred dominance of lactobacilli bacteria. The vaginal micro-biome is healthiest when there is a lower pH (therefore more acidic than alkaline), a lower diversity of bacteria dominated by high levels of lactobacilli keeping unfavourable bacteria in check. Low levels of lactobacilli is associated with a higher pH and a higher incidence of unfavourable bacteria that can lead to infection such as bacterial vaginosis.
As estrogen levels decline, the vaginal lining begins to thin which leads to less fuel by way of glycogen for the lactobacilli to ferment and reproduce leading to reduced lactic acid production and an increase in pH which may lead to increased proliferation of harmful organisms such as E. coli and Gardnerella. Vaginal atrophy leads to dryness which can affect sexual health/enjoyment and due to less secretions/lubrication the vaginal wall becomes vulnerable to damage during sex which can become painful and further increase the risk of infection. The increased risk of infection includes STI’s so even though unplanned pregnancy may not be an issue for the menopausal woman, safe sex needs to be considered with new partners.
Vaginal dryness experienced as a result of menopause can significantly impact the quality of physical intimacy in relationships and lubricants/vaginal moisturising products can be useful. From a lubricant perspective, it’s ideal to use a natural product that won’t interfere with vaginal pH and expose already vulnerable membranes to more irritation with synthetic ingredients. ‘YES’ is a brand which produces good quality natural lubricants and vaginal moisturisers and is available on-line. Organic coconut oil can also be very useful as a lubricant however its important to avoid oil based lubricants if using condoms.
Hormone replacement therapy (HRT) will usually improve menopausal vaginal issues as it’s providing estrogen back into the body. There are possible unfavourable side effects of taking HRT systemically so some women prefer to use vaginal estrogen pessaries so they can benefit from increased estrogen levels directly presented into the vaginal area. This appears to not increase systemic estrogen while still providing benefits locally to the vagina. In severe cases of vaginal dryness and atrophy, some gynaecologists are offering laser therapy such as ‘Mona Lisa touch therapy’ and EVA laser therapy.
A naturopathic approach to supporting menopausal vaginal health aims to support optimal hormone balance, maintain healthy vaginal microbiome, improve natural lubrication and vaginal health with the intention of reducing the incidence of urinary tract and vaginal infections as well as improving comfort generally and during physical intimacy. Diet and lifestyle are addressed usually with recommendations specific to individual requirements and taking into consideration prescribed medications and personal health history.
Other issues that need to be ruled out when investigating genitourinary syndrome in menopause include vaginal dermatitis, lichen sclerosis/planus, chronic vulvo-vaginal candidiasis, diabetes mellitus, urinary tract infection and vaginitis. A visit to your GP can assist with this.
Acknowledgment: Moira Bradfield-Strydom intimate ecology specialist.
Diana Arundell is a university-qualified naturopath and consults from her Avoca Naturopath clinic. She has a special interest in fertility and pregnancy health, digestive health, immune function and family wellness programs. She was a nutrition lecturer at Macquarie University for 10 years, and is an accredited Journey Practitioner. For further information or to make an appointment please contact Diana Arundell at Avoca Naturopath on 0410 465 900.