Vaginal Health in Perimenopause: What to Expect

14 min read
Vaginal Health in Perimenopause: What to Expect

Perimenopause can affect more than your periods.

As hormone levels fluctuate and gradually change, some people notice vaginal dryness, burning, irritation, less natural lubrication, discomfort during sex or changes in bladder symptoms.

Others notice very little change at all.

These symptoms can be part of genitourinary syndrome of menopause, or GSM, which affects the vagina, vulva and lower urinary tract.

The good news is that these changes are treatable. Depending on what’s bothering you, options can range from vaginal moisturisers and personal lubricants to pelvic health physiotherapy and prescription vaginal oestrogen.

Key takeaways

  • Vaginal and vulval changes during perimenopause are common but not inevitable.
  • Lower and fluctuating oestrogen can affect vaginal moisture, elasticity, sensitivity and the urinary tract.
  • Vaginal moisturisers are designed for ongoing dryness, while lubricants reduce friction during sex or insertion.
  • Low-dose vaginal oestrogen can be a very effective treatment when symptoms are related to lower oestrogen.
  • Pelvic floor symptoms don’t automatically mean the muscles are weak or that you need more Kegel exercises.
  • Pain, unusual discharge, urinary symptoms or unexpected bleeding shouldn’t automatically be blamed on perimenopause.
  • Any vaginal bleeding after menopause needs medical assessment.

On this page

What is perimenopause?

Perimenopause is the transition leading up to menopause.

It often begins in the 40s, although it can start earlier or later. During this time, ovarian hormone levels fluctuate and periods may become less predictable.

You might notice periods becoming heavier, lighter, closer together or further apart, along with symptoms such as hot flushes, sleep changes, brain fog or mood changes.

Menopause is your final menstrual period and is confirmed retrospectively once 12 months have passed without another period and there is no other explanation.

Our complete guide to menopause explains the transition, symptoms and treatment options in more detail.

How can perimenopause affect vaginal health?

Oestrogen plays an important role in maintaining the vagina, vulva and lower urinary tract.

As oestrogen fluctuates and eventually declines, vaginal and vulval tissue can become drier, thinner, less elastic and more sensitive.

These changes don’t happen to everyone at the same age or with the same severity.

Vaginal and vulval tissue can become drier and more sensitive

Oestrogen helps maintain the thickness, elasticity, blood supply and moisture of vaginal tissue.

With lower oestrogen, some people begin to notice:

  • dryness or tightness
  • burning or stinging
  • itching or irritation
  • greater sensitivity to friction
  • soreness around the vaginal opening or vulva

Similar symptoms can also come from dermatitis, infections, vulval skin conditions or irritation from personal care products, so persistent symptoms are worth checking.

Natural lubrication may change

You may notice less lubrication during sexual arousal or simply feel drier during everyday life.

That can make penetrative sex, masturbation or inserting a menstrual cup, disc, tampon or other product less comfortable than it used to be.

Needing lubricant doesn’t mean you aren’t aroused or interested in sex. Hormones can affect lubrication independently of desire.

If dryness is your main concern, our guide to vaginal dryness looks at treatment options in more detail.

The vaginal environment changes

Before menopause, oestrogen helps support an acidic vaginal environment and bacteria such as Lactobacillus species.

As oestrogen declines, particularly after menopause, vaginal pH tends to rise and the vaginal microbiome can change.

These changes are part of the GSM picture, but they don’t mean you’ll automatically develop thrush or bacterial vaginosis.

In fact, thrush generally becomes less common after menopause unless there are other contributing factors.

If you notice unusual discharge, a persistent smell, significant itching or irritation, don’t automatically assume hormones are responsible.

Our guide to vaginal discharge and how it changes explains what tends to be normal and when it is worth getting checked.

Urinary symptoms can appear too

Oestrogen also affects the urethra and bladder.

Some people notice:

  • needing to urinate more often
  • sudden urinary urgency
  • burning or discomfort when urinating
  • recurrent urinary tract infections
  • bladder leakage

Burning or urinary urgency can also be caused by a urinary tract infection, so new symptoms shouldn’t simply be put down to menopause.

If leaking is bothering you, see our guide to light bladder leakage.

Sex or penetration may feel different

Lower oestrogen can reduce the elasticity and flexibility of vaginal tissue.

For some people, the vaginal opening may feel tighter or penetration may become uncomfortable, particularly when dryness or irritation is also present.

That doesn’t mean sex has to stop.

Lubricant, more time for arousal, different sexual activities and treatment for vaginal dryness can all help.

And importantly, pain isn’t something you need to push through.

Dryness is only one possible cause of painful penetration. Pelvic floor muscle tension, skin conditions, infections, endometriosis and other pelvic health conditions can also contribute.

Read more in our guide to painful intercourse and dyspareunia.

What is genitourinary syndrome of menopause?

Genitourinary syndrome of menopause, usually shortened to GSM, describes a group of genital, vaginal and urinary changes associated with lower sex hormone levels around and after menopause.

GSM was previously described using terms such as vaginal atrophy or atrophic vaginitis, but those terms don’t capture the fact that the vulva, bladder and urinary tract can be involved as well.

Symptoms can include:

  • vaginal dryness or reduced lubrication
  • vulval dryness or irritation
  • itching, burning or soreness
  • pain during sex or penetration
  • urinary urgency or frequency
  • discomfort when urinating
  • recurrent urinary tract infections

GSM symptoms can begin during perimenopause and become more noticeable after menopause.

Unlike hot flushes, which often become less frequent over time, genital and urinary symptoms caused by lower oestrogen may persist or gradually worsen without treatment.

That doesn’t mean every vaginal or bladder symptom in midlife is GSM, so it’s worth getting ongoing or troublesome symptoms assessed.

How can you manage vaginal changes during perimenopause?

The right approach depends on what you’re experiencing.

Occasional friction during sex may only require lubricant. Day-to-day dryness may respond better to a moisturiser. Persistent symptoms related to lower oestrogen may respond very well to vaginal oestrogen.

Some people use more than one approach.

Vaginal moisturisers

Vaginal and intimate moisturisers are designed for ongoing dryness rather than just sexual activity.

Depending on the product, they’re usually applied regularly to help keep tissue more comfortable between sex or other activities.

Follow the instructions for your particular product because some moisturisers are designed for internal vaginal use while others are intended for the external vulval area only.

Personal lubricants

Personal lubricants provide temporary slip and reduce friction.

They can be useful during:

  • penetrative sex
  • masturbation
  • inserting menstrual cups or discs
  • using vaginal dilators or other devices
  • pelvic examinations where appropriate

Water-based lubricants are versatile and generally compatible with latex condoms and most toys and devices.

Silicone-based lubricants usually stay slippery for longer, although you should check compatibility with silicone products.

Oil-based products can damage latex condoms.

Our guide to choosing a personal lubricant explains the differences.

Gentle vulval care

Dry or sensitive tissue can become irritated by products that never bothered you before.

It may help to:

  • wash the external vulva gently with water or a simple fragrance-free product if needed
  • avoid douching
  • avoid fragranced intimate washes, deodorants and wipes
  • stop using products that sting or cause irritation
  • choose underwear and clothing that feel comfortable and don’t create unnecessary friction

The vagina is self-cleaning and doesn’t need internal washing.

Read our guide to douching and vaginal health for more.

What about vaginal oestrogen?

If vaginal or urinary symptoms are being driven by lower oestrogen, low-dose vaginal oestrogen can be a very effective treatment.

It is applied directly to vaginal tissue rather than being used to provide hormone treatment throughout the whole body.

In Australia, vaginal oestrogen is available in preparations including creams, vaginal tablets and ovules.

It can help improve:

  • vaginal dryness
  • irritation and burning
  • pain during sex
  • vaginal tissue thickness and elasticity
  • some urinary symptoms
  • recurrent urinary tract infections in some postmenopausal people

Only a very small amount of oestrogen is absorbed into the bloodstream when low-dose vaginal oestrogen is used as recommended.

A progestogen generally isn’t required solely because you’re using standard low-dose vaginal oestrogen, even if you still have a uterus.

Vaginal oestrogen can also be used alongside systemic menopausal hormone therapy if local vaginal symptoms continue.

It can take several weeks to get the full effect, so it isn’t necessarily an instant treatment.

What if you’ve had breast cancer?

If you’ve had breast cancer, moisturisers and lubricants are generally the first options to try.

If symptoms remain troublesome, vaginal oestrogen may sometimes still be considered after discussion with your GP, oncologist or breast cancer specialist.

This is particularly important if you use an aromatase inhibitor, because these medicines are designed to keep oestrogen levels extremely low.

Having had breast cancer doesn’t mean you should simply accept severe vaginal or urinary symptoms. It means treatment needs to take your individual cancer history and medicines into account.

What about systemic MHT?

Menopausal hormone therapy, or MHT, may improve vaginal symptoms as well as hot flushes, night sweats and other menopause-related symptoms.

But some people still experience vaginal dryness or GSM while using systemic MHT and may benefit from vaginal oestrogen as well.

Our menopause guide explains MHT and other treatment options in more detail.

What about the pelvic floor?

Vaginal or urinary changes during perimenopause don’t automatically mean your pelvic floor muscles are weak.

The pelvic floor needs strength, coordination and the ability to relax.

Some people experience weakness and bladder leakage. Others develop tight or overactive muscles that contribute to pain during sex, difficulty inserting products or pelvic pain.

This is why simply doing more Kegel exercises isn’t always the answer.

If you have bladder leakage, a feeling of heaviness or dragging, a vaginal bulge or ongoing pelvic pain, a pelvic health physiotherapist can assess what your muscles are actually doing.

You can use our directory to find a pelvic health physiotherapist.

For more background, read our guide to the pelvic floor and Kegel exercises.

What about vaginal laser and radiofrequency treatments?

Laser and radiofrequency treatments have been promoted for vaginal dryness, painful sex, urinary symptoms and so-called vaginal rejuvenation.

In Australia, this has changed significantly.

The Therapeutic Goods Administration reviewed energy-based devices marketed for vaginal rejuvenation and found insufficient clinical evidence to support their therapeutic use and long-term safety.

Following that review, all energy-based devices intended for vaginal rejuvenation that had been included in the Australian Register of Therapeutic Goods were cancelled by the TGA or their sponsors.

There are currently no energy-based devices included in the ARTG for vaginal rejuvenation.

If you’re considering laser or radiofrequency treatment for vaginal or urinary symptoms, it’s worth discussing the evidence and alternative treatments with your GP or menopause clinician first.

What about trans men and people using testosterone?

Genital dryness and tissue changes aren’t exclusive to perimenopause.

Some trans men, transmasculine and non-binary people using testosterone experience vaginal or front-hole dryness, irritation, tissue sensitivity or discomfort during penetration.

These changes can resemble some aspects of GSM because testosterone can create a lower-oestrogen environment in local genital tissue, but this doesn’t mean testosterone has caused natural menopause.

Lubricants, moisturisers and sometimes low-dose local oestrogen can be options depending on the symptoms and the person’s preferences.

For more on periods stopping or returning, pregnancy risk, genital dryness and period care while using testosterone, read our guide to periods, testosterone and transition for trans men and transmasculine people.

When should you see a doctor?

You don’t need to wait until vaginal or urinary symptoms become severe before asking for help.

See your GP or another appropriate healthcare professional if:

  • dryness, burning or itching keeps returning
  • symptoms interfere with everyday life, exercise, sex or sleep
  • penetration or inserting products is painful
  • you have unusual or persistent discharge
  • you notice a strong or unusual odour
  • you have pain or burning when urinating
  • you keep getting urinary tract infections
  • you notice a vaginal bulge, heaviness or dragging sensation
  • you have persistent pelvic pain

Changes in bleeding

Changes in periods are common during perimenopause, but not every bleeding change should automatically be attributed to hormones.

Talk with your GP if you have:

  • very heavy bleeding
  • bleeding between periods
  • bleeding during or after sex
  • a bleeding pattern that is significantly different from your usual pattern

Any vaginal bleeding after menopause needs medical assessment, even if it is only light spotting or happens once.

If you’re not sure how to start the conversation, our guide to talking to a doctor about vaginal concerns can help.

Frequently asked questions

Can perimenopause cause vaginal dryness?

Yes. Fluctuating and declining oestrogen can reduce vaginal moisture and affect tissue thickness and elasticity. Some people notice dryness during perimenopause while others don’t experience it until after menopause, or at all.

Does vaginal dryness go away after menopause?

Not necessarily. Unlike some symptoms such as hot flushes, GSM-related vaginal and urinary symptoms may continue or become more noticeable after menopause. Moisturisers, lubricants and vaginal oestrogen are among the treatment options.

What’s the difference between a vaginal moisturiser and lubricant?

A vaginal moisturiser is used regularly to help with ongoing dryness. Lubricant provides temporary slip when you need it, such as during sex or insertion. Many people use both.

Can perimenopause cause painful sex?

Yes. Lower oestrogen can contribute through dryness, tissue sensitivity and reduced elasticity. Pain can also come from pelvic floor muscle tension, skin conditions, infections and other pelvic health issues, so ongoing pain is worth assessing.

Can perimenopause cause urinary problems?

It can. Hormonal changes can affect the urethra and bladder as well as vaginal tissue. Some people notice urgency, frequency or recurrent urinary tract infections. Because these symptoms also have other causes, new or persistent urinary problems should be checked.

Do I need to do Kegel exercises during perimenopause?

Not automatically. Some pelvic floors need strengthening, while others are tight or overactive and need relaxation and coordination work instead. If you have leaking, heaviness, pain or difficulty with penetration, a pelvic health physiotherapist can help work out what your muscles need.

Is vaginal oestrogen safe?

Low-dose vaginal oestrogen has very low systemic absorption and is considered a safe and effective treatment for GSM for most people. At recommended local doses, a progestogen generally isn’t required. If you’ve had breast cancer or another hormone-sensitive condition, discuss your individual situation with your GP and specialist team.

Can I use vaginal oestrogen if I’m already taking MHT?

Yes, vaginal oestrogen can sometimes be used alongside systemic MHT when vaginal or urinary symptoms persist. Your prescriber can advise whether it is appropriate for you.

Does vaginal laser treatment work for GSM?

Energy-based vaginal laser and radiofrequency treatments have been marketed for GSM, but the Australian TGA found insufficient evidence to support their therapeutic use and long-term safety. There are currently no energy-based devices included in the ARTG for vaginal rejuvenation.

Can testosterone cause similar vaginal changes?

Yes. Some people using masculinising testosterone experience vaginal or genital dryness, tissue sensitivity and discomfort with penetration. This can resemble some GSM symptoms but isn’t the same as natural menopause. Our periods and testosterone guide explains this in more detail.

Your comfort 

Vaginal and urinary changes are common during the menopause transition, but common doesn’t mean you have to put up with them.

Sometimes a good lubricant is enough. Sometimes regular moisturiser makes everyday life much more comfortable. And when lower oestrogen is driving persistent symptoms, vaginal oestrogen can be a very effective treatment.

The right solution depends on your symptoms and your body.

You also don’t need to accept painful sex, ongoing irritation or bladder problems as an inevitable price of getting older.

If something is affecting your comfort or quality of life, there are options worth exploring.

Related reading

Sources and further reading

This article provides general educational information and isn’t a substitute for individual medical advice.