Why is Vaginal Dryness so Common with Menopause and Perimenopause?

Menopause is defined as the cessation of menstrual cycles that occurs when a woman stops ovulating permanently due to a loss of eggs (ovarian follicles). As part of this process, the ovaries stop producing large amounts of estrogen (and progesterone). It is only diagnosed after a woman has not had a period for 12 months. The average age of menopause in the United States is 51 years old but it is possible to experience it at a much earlier age. About 1% of women will experience menopause before age 40 (premature menopause) and 5% will experience it before age 45.

Perimenopause is defined as the transition from having regular menstrual cycles to the complete cessation of menstrual cycles. It usually begins when a woman who previously had cycles that were regular with a predictable length begins having irregular periods before eventually having no periods at all. Women enter perimenopause on average about 4 years before they stop having periods altogether.  

It is in this early period just before menopause when symptoms like vaginal dryness can start to appear. The most common symptom during perimenopause and menopause is hot flashes, which is estimated to occur in over 75% of women during midlife, but vaginal dryness is also remarkably common.

Subtle changes occur throughout the reproductive system, including the vagina—and unlike hot flashes and other general menopausal symptoms, vaginal changes do not improve with time, and often worsen with each passing year. The decreasing levels of estrogen cause the vaginal tissue and the vulvar skin (outer lips of the vagina) of the genitals to become atrophic—meaning the skin begins to lose its normal, thick structure.

The vagina also becomes more susceptible to yeast and other infections. The once healthy balance of organisms that was supported by a slightly acid, vaginal environment is altered in the less acidic, estrogen-deprived vagina of menopausal women.The term used to describe all the changes that occur in the vagina and vulva is vulvovaginal atrophy (VVA).

Other symptoms related to the loss of estrogen in the genital region include urinary tract symptoms (e.g., frequent urination, a sense of urgency, loss of urine with stress, need to urinate at night) since the skin in the area of the urethra (the tube that carries urine) is affected by the loss of estrogen.

Taken together, symptoms of menopause involving the vaginal tissue and the urinary tract are called the Genitourinary Syndrome of Menopause (GSM). You will often see vulvovaginal atrophy (VVA) and Genitourinary Syndrome of Menopause (GSM) lumped together as VVA/GSM. GSM includes all the symptoms that may occur and respond to therapy as described below.

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