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Do you ever feel like your vagina is pressing into your vulva? Or that you have shooting pains in your bits like knitting needles?  Is it uncomfortable to walk at times?  You are not alone!

Itching, burning and sore vulvas, vaginal dryness, painful sex, feeling like you have thrush or a urine infection can all be signs that you have vulvo-vaginal atrophy (VVA).

VVA is widely reported to affect 70% of menopausal women but as only around 7% get treatment, that figure could actually be far higher.

Lisa told me she had no idea what was happening to her when her symptoms first started a few months ago at 49. She thought she was suffering a prolapse or scarily worse. None of her friends she spoke to knew either. Catherine said the pain was so intense at times it was as if knitting needles were being poked into her vagina.  At its worse, Jacqui could not sit down or walk, the pain was so excruciating.  All these women were subsequently diagnosed with VVA but not without a fight to get their symptoms taking seriously.

VVA doesn’t just affect women of a certain age. Freya first noticed symptoms 8 weeks after having her baby.  Within a week she had become more aware of pain in her vagina and inner labia (the lips of the vulva) while walking, and progressively symptoms became even more painful with a feeling that the vagina was putting pressure on the vulva.

After birthing a 9lb baby 6 months earlier, my GP told me that the discomfort I was having was due to having been stitched too tight (yikes) and a new diagnosis of lichen sclerosis so I was referred to a gynaecologist. By the time I got to see the gynaecologist several months later, I’d stop breastfeeding and my tightness had resolved.  At no point was I told by my GP that my reduced oestrogen enabling me to breastfeed was causing my vagina to be tight.

My blog on the wonders of our cervical fluid touched on how oestrogen can affect how much cervical fluid we might have.  Oestrogen levels can drop at any time, but typically happens during times of stress, breastfeeding and perimenopause as well as after menopause. 

Menopause (when a woman has not had a period for over 12 months) is usually preceded by some years where periods are irregular – the ‘perimenopause’ (unless menopause is medically or surgically induced) and includes the hot flushes we all know about, as well as joint and muscular pain, mood changes, brain fog, a lower sexual desire and urogenital problems. Every woman is different.

This is all caused by a decrease in oestrogen which affects every tissue in our body including those in our bladders and vaginas. With less oestrogen, our vaginas shorten and narrow and the lining becomes thinner and less elastic. Cervical fluid is reduced and vaginal PH changes. All symptoms of VVA, part of ‘genitourinary syndrome’ (GSM).

Vaginal dryness is probably the most talked about symptom of VVA. However, dryness implies something that can be sorted out with a bit of moisturiser in the right place.  It does not do justice to the wide ranging symptoms of VVA and the sheer pain and discomfort women feel. As it is the cells that are affected the vagina itself may still feel moist even though there are symptoms of VA.

 Whilst it is a natural part of the ageing process, treatments are available which can really help symptoms.

In the UK on the NHS, options include:

• Oral or topical systemic hormone replacement therapy (HRT) as a patch or gel usually a combination of oestrogen and progesterone and occasionally testosterone given as a gel.  This is not always a necessary start to treating VVA.

• Vaginal low dose oestrogen given as a cream, pessary, tablet or ring, that can be used alongside HRT or as a stand-alone even if HRT is contra-indicated. Dosages and frequency of application can be adjusted so do discuss this with your doctor if you are not finding relief. The amount of oestrogen released into the blood stream is very low and symptoms may come back if treatment is stopped. Hormone therapy can be lifelong if required.  In other countries, compounded creams are available that are tailored to your needs.

• Ospemifene taken orally is suitable for women who have had breast cancer treatment or who don’t want to use anything vaginally or hormonal.

Other things you can try to help VVA include:

• Vaginal Moisturisers and Lubricants – whilst they do not address the underlying cause of VVA, moisturisers can offer temporary relief from symptoms if used regularly and lubricants can help with vaginal dryness and pain during sex. 

There are many products available over the counter but they are not all created equal. The vagina has its own microbiome (like your gut) and can be more sensitive to ingredients in products when oestrogen deficient. Some contain ingredients that can irritate and burn so a more natural product like YES or vegan and organic Into the Wylde may suit some women better. They can be used on their own or in combination with systemic or topical hormone replacement therapy.  It can take trial and error to find one that suits you but it is worth persisting. Some have hyaluronic acid which helps plump up and brings significant temporary relief such as Canesintima.

• Vaginal DHEA – studies have shown topical DHEA (which converts to oestrogen and testosterone in cells) can significantly improve symptoms. Julva contains natural DHEA and was developed by an American OBY-GYN.
• Hyaluronic acid – in studies it has been found to work as well as vaginal oestrogen for temporary relief.
• Exercise – not being overweight may improve symptoms.
• Diet – nutritionally eating plant oestrogens such as legumes, nuts seeds and fermented soya such as tempeh and miso can help to boost oestrogen levels.  Fermented foods such as kimchi, sauerkraut, kombucha and kefir as well as avoiding sugar encourages a healthy vaginal microbiome. Avoid caffeine and alcohol. Our nutritional therapist Tamar can help if y you need further advice.
• Homeopathy – can be used on its own or alongside other treatments and individualised to your own unique symptoms on a physical and mental basis. 
• For breastfeeding mums, symptoms usually ease after weaning, but some women can be affected until they stop completely.  It is possible for new mums to be prescribed oestrogen cream but it’s a fine balance to not affect milk production. 
• Use natural products – Avoid having a bath as this can affect vaginal PH.  And avoid shower products that are highly scented or contain artificial chemicals as they can irritate. 
• Dilators – again contentious in their helpfulness.  Dilators and lubricants do not address what is wrong with the cells – the lack of oestrogen giving them elasticity. However, other women told me that gentle stretching before intercourse was helpful.
• Pelvic floor muscle training improved some VVA symptoms in women using topical oestrogen.
• Vitamin D and Vitamin E suppositories – studies have found they improved VVA and vaginal PH.
• Sea buckthorn oil as a supplement can positively affect vaginal health and elasticity. In one study, taking this as a supplement had a similar efficacy as topical oestrogen.
• Magnesium – nicknamed ‘natures tranquilizer’ by some psychologists, can help relax the nervous system and improve sleep. Both of which can impact on our oestrogen levels.

There are some suggestions that increasing blood flow to the vagina with regular sexual activity may help. However, all the women I spoke to said that even a finger was too big when their VVA was at its worst, due to pain and tightness.  This suggestion apportions blame to a woman who may already be feeling frustrated with their bodies and guilty. Which is not warranted and unjust.

Dr Catherine Pestano (an Early Career researcher at the University of Winchester and who is currently running an open menopause research group) feels that most women don’t understand what is happening to them and so cannot describe it to doctors.  Doctors are also likely to be unaware of what is happening to the women they see in front of them.  I apologise to any doctors who do understand VVA but the reality is that ALL the women I spoke to had to see several doctors before they were taken seriously and many women resorted to seeing a private doctor before they received adequate treatment.  I even heard of one woman being asked why she wanted treatment for VVA when she wasn’t having sex!

VVA has an extensive effect on a woman’s’ quality of life, yet is not widely discussed, is underreported and undertreated. That needs to change.  If you think you have VVA talk to your doctor.  Ensure you get treatment and if that treatment doesn’t work persist with seeking medical advice.  Dr Pestano said that there are other conditions that can co-occur or seem like VVA or are often part and parcel of the changes during menopause.  For example, bacterial vaginosis or Lichen Sclerosus which can cause intense itching.  And so, addressing this can bring some elements of relief with products such as bioflor and canesflor. You can also be referred to a menopause specialist.  Do not suffer in silence and assume this is just part of getting older.

I’m sure this won’t be my only exploration of this issue.  I’d love to hear your own experience and what has worked or not worked for you.  Thank you to the women who spoke to me candidly about their symptoms. 

Becca x

Menopause Did you Know?

• The average age of menopause is 51 although 1 in 100 women experience menopause before they are 40.
• According to the UKs’ NHS NICE guidelines x:
  • women over 45 should be diagnosed as being in perimenopause and menopause based on symptoms alone – you do not need blood tests. 
  • Reviews of treatment from your GP should be carried out after 3 months to assess efficacy and tolerability and then annually unless side effects develop. 
  • there is no clear evidence for the use of anti-depressants to ease low mood in menopausal women who have not been diagnosed with depression. It is not all in your head and you are not going mad!
  • Referral to a menopause expert should take place if treatment does not improve symptoms or you develop side effects.
• There is a real lack of menopause specialist centres in many parts of the UK.
• VA can cause itching.  Regular monthly examinations of your vulva (like breast examinations) are crucial to ensure you know what your own body looks and feels like and to be aware of any changes.  White patches as well as itching can be a sign of lichen sclerosus.
• There are 5 types of gynaecological cancers that can affect women – cervical, womb, ovarian, vaginal and vulval.  So any unusual lumps and bumps, bleeding, discharge or concerning changes should always be checked out with your GP. 

References:

1. Dr Catherine Pestano is an Early Career researcher at the University of Winchester, and is currently running an open menopause research group.
2. Post Reprod Health. 2020 Jun;26(2):101-109. doi: 10.1177/2053369120925193. Symptoms, attitudes and treatment perceptions of vulvo-vaginal atrophy in UK postmenopausal women: Results from the REVIVE-EU study Claudine Domoney, Hannah Short, Martire Particco , Nick Panay 
3. Climacteric. 2016 Apr;19(2):151-61. doi: 10.3109/13697137.2015.1124259. Epub 2015 Dec 26.Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition? D Edwards, N Panay
4. The British Menopause Society https://www.youtube.com/watch?v=ZVRMLmR_cnU&t=3s
5. J Sex Med. 2021 Jan;18(1):156-166. doi: 10.1016/j.jsxm.2020.10.016. Epub 2020 Dec 5. Hyaluronic Acid in Postmenopause Vaginal Atrophy: A Systematic Review, Carlos Campagnaro M Dos Santos , Maria Laura R Uggioni , Tamy Colonetti , Laura Colonetti , Antonio José Grande , Maria Inês Da Rosa 
6. Menopause. 2016 Jul;23(7):816-20. doi: 10.1097/GME.0000000000000620. Pelvic floor muscles training to reduce symptoms and signs of vulvovaginal atrophy: a case study Joanie Mercier, Mélanie Morin, Marie-Claude Lemieux, Barbara Reichetzer, Samir Khalifé, Chantale Dumoulin
7. Support Care Cancer. 2019 Apr;27(4):1325-1334. doi: 10.1007/s00520-019-04684-6. Epub 2019 Feb 7. The effect of vitamin D and E vaginal suppositories on tamoxifen-induced vaginal atrophy in women with breast cancer. Zahra Keshavarzi , Roksana Janghorban , Shohreh Alipour , Sedigheh Tahmasebi , Azam Jokar 
8. Larmo, P. S., Yang, B., Hyssala, J., Kallio, H. P., & Erkkola, R. (2014, November). Effects of sea buckthorn oil intake on vaginal atrophy in postmenopausal women: A randomized, double-blind, placebo-controlled study. Maturitas, 79(3), 316-321

Resources and Women raising awareness of Menopause and VA

Menopause NICE Guidelines: https://www.nice.org.uk/guidance/ng23/resources/menopause-diagnosis-and-management-pdf-1837330217413

The British Menopause Society

Vaginal Atrophy Self Help Facebook Group

Davinia McCall and her Documentary – Sex, Myths and the Menopause available on All4

Meg Matthews and her new book – ‘The New Hot, taking on the menopause with attitude and style (2020), Vermilion, UK.

Turning Back the Clock on Your Vagina – Lauren Streicher, (2021), USA

Me and My Menopausal Vagina: Living with Vaginal Atrophy – Jane Lewis, (2018), PALS, UK

Naomi Potter and Lisa Snowden on Instagram

Davinia Taylor on Instagram

Menopause and Employment Law – https://henpicked.net/category/menopause-hub/menopause-and-work/