Vaginal Dryness in Menopause: Causes & What Helps

Vaginal dryness is one of the most common symptoms of the menopause, and one of the least discussed. In my clinic I meet women who have quietly put up with soreness, discomfort during sex or repeated urine infections for years — often assuming nothing can be done, or feeling too awkward to raise it. I would like to change that. The medical name for this cluster of symptoms is the genitourinary syndrome of menopause (GSM). It affects up to around eight in ten women after the menopause, it rarely improves on its own, and — this is the important part — it responds very well to treatment.

What is genitourinary syndrome of menopause (GSM)?

GSM is the umbrella term for the changes that affect the vulva, vagina and lower urinary tract when oestrogen levels fall. You may have heard the older names, "vaginal atrophy" or "atrophic vaginitis". In 2014 an international group of specialists agreed to replace them with GSM — partly because "atrophy" is an unkind word to attach to a woman's body, and partly because the older terms ignored the urinary symptoms, which are just as common.

The syndrome groups vaginal symptoms (dryness, irritation, discomfort) together with urinary ones (urgency, frequency, recurrent infections), because they share a single underlying cause: a lack of oestrogen.

Why it happens: the oestrogen connection

Oestrogen keeps the tissues of the vulva, vagina and urethra thick, elastic and well lubricated, and it maintains the slightly acidic environment that keeps the vaginal microbiome healthy. As oestrogen falls during perimenopause and after the menopause, those tissues become thinner, drier and less stretchy, and the vaginal pH rises. That is what produces the symptoms — and why they tend to appear gradually and then persist.

The symptoms: more than dryness

GSM is far broader than the word "dryness" suggests. The symptoms I hear about most often are:

• Vaginal dryness, burning or itching
• Soreness or irritation day to day
• Pain or discomfort during sex, and sometimes light bleeding afterwards
• Needing to pass urine more often, or more urgently
• Discomfort when passing urine
• Recurrent urinary tract infections

That last point matters. Falling oestrogen is a recognised cause of recurrent UTIs after the menopause, and it is often missed — women are given antibiotic after antibiotic without anyone addressing why the infections keep coming back.

Why GSM does not go away on its own

This is the key difference between GSM and other menopausal symptoms. Hot flushes and night sweats usually ease over several years as the body adjusts. GSM does the opposite: because the oestrogen deficiency is ongoing, the symptoms tend to stay the same or slowly worsen if they are left untreated. The encouraging news is that it is very treatable at any stage — it is never "too late" to feel comfortable again.

What actually helps

Treatment is usually straightforward, and we match it to how much the symptoms are affecting you.

• Vaginal moisturisers — used regularly, every few days, these are absorbed into the vaginal tissue to keep it comfortable day to day. They are non-hormonal and available without a prescription; products containing hyaluronic acid suit many women.
• Lubricants — used at the time of sex to reduce friction and discomfort. Also non-hormonal, and they work well alongside a moisturiser.
• Vaginal (local) oestrogen — a prescription treatment that delivers a very small dose of oestrogen straight to the tissues, as a cream, pessary, tablet or ring. It is the most effective option for moderate to severe GSM because it treats the cause, restoring the tissue rather than simply masking the symptoms.
• Other options — for some women, vaginal DHEA (prasterone) or an oral medicine called ospemifene may be appropriate.

A distinction people often ask about: a moisturiser is used regularly to keep the tissues comfortable, while a lubricant is used at the moment of sex. They do different jobs, contain no hormones, and are frequently used together.

Is vaginal oestrogen safe?

This is the question I am asked most, and the fear of "hormones" stops many women from getting effective treatment — so it is worth being clear. For most women, low-dose vaginal oestrogen is very safe. It works locally, with only a tiny amount absorbed into the bloodstream, so it does not carry the risks people associate with systemic HRT. It is supported by national guidance, it can be used long term, and — unlike HRT taken for hot flushes — vaginal oestrogen does not require a progestogen to protect the womb lining.

It is quite different from the systemic HRT used for whole-body symptoms such as flushes and mood: vaginal oestrogen is a small, local treatment aimed only at the genitourinary tissues.

GSM is not only about the menopause

Although the menopause is the most common cause, any state of low oestrogen can produce the same symptoms — including breastfeeding and the months after childbirth, some hormonal contraceptives, premature ovarian insufficiency, and menopause brought on by cancer treatment. The symptoms, and the treatments, are much the same.

A note for women treated for breast cancer

GSM is very common after breast-cancer treatment, particularly with aromatase inhibitors, and it can have a real impact on quality of life. Non-hormonal measures — moisturisers and lubricants — are the first-line approach and are enough for many women. If they are not, vaginal oestrogen may still be an option for some, but it is an individual decision that must be made together with your oncology team, and it is generally avoided while you are taking an aromatase inhibitor. Because this deserves a fuller, careful answer, I have written a separate guide on vaginal dryness and sexual health after breast cancer.

The effect on intimacy

When sex becomes painful, it is natural to start avoiding it, and that can affect confidence and relationships. I want women to know that this is a physical, treatable problem — not something you simply have to accept as part of getting older. It is also worth separating from low desire, which tends to have different and often several causes. Many women are surprised by how much difference a few weeks of the right treatment can make.

When to see a specialist

It is worth seeking help if simple measures are not enough, if symptoms are affecting your sleep, comfort or sex life, if you have recurrent urine infections, or — importantly — if you have any vaginal bleeding after the menopause, which always needs to be assessed. In clinic I take time to talk through your symptoms, examine where appropriate, rule out other causes, and put together a plan that suits you. You do not need a GP referral to be seen privately.

This article is for general information and does not replace personal medical advice. If you have symptoms or concerns, please book an appointment or speak to your GP. In an emergency, call 999.