Vaginal Dryness and Bladder Changes in Menopause: What Helps

Dry. Sore when you sit for too long. Sex that used to be fine now stings, or you've quietly stopped. You know where every toilet is on the way to work, and you've had more urine infections this year than you'd like to count.

It's often the thing women mention last in a consultation, almost on the way out. It feels too personal, or just part of getting older. Or you mentioned it once and went home with a thrush cream that didn't help.

So here's what's going on, why it tends to stay, and what helps.

What's actually happening

It has a name: GSM (genitourinary syndrome of menopause). That means the changes to the vagina, the vulva (the outside part) and the bladder that come with lower oestrogen.

Oestrogen keeps those tissues thick, stretchy and moist. As it falls, they get thinner, drier and more fragile. The vagina also becomes less acidic, so the bacteria that cause bladder infections find it easier to settle in.

That's why these come as a group:

• dryness, itching or burning
• soreness, and skin that splits easily
• pain with sex, or avoiding it because it might hurt
• needing to wee more often, or rushing to get there in time
• getting up in the night to wee
• UTIs (urinary tract infections) that keep coming back

It can start in perimenopause, and often shows up a few years after the last period. Women with an early menopause get it too.

Why it does not settle by itself

Hot flushes usually ease with time. GSM usually does not. Without treatment it tends to stay, and it often gets worse over the years, because the tissue keeps thinning while oestrogen stays low.

Waiting for it to pass, the way the flushes did, usually just means more months of it.

It usually responds well to treatment. It just needs checking first. Thrush, other infections, a skin condition of the vulva or a bladder problem can all feel the same. If the itching keeps coming back, it needs an examination, because a skin condition called lichen sclerosus can feel just like thrush. Where an examination is needed, that's part of the plan we make together.

What helps at home

Wash with less. Shower gel, bubble bath, wipes and anything scented all strip skin that's already fragile. For the vulva, water is enough, or a plain unperfumed emollient (a moisturising soap substitute).

A moisturiser and a lubricant are 2 different things. A vaginal moisturiser is used at least twice a week, whether or not you're having sex. A lubricant is used just before sex. Water-based and silicone-based are both fine; oil-based can damage latex condoms. Many women use both.

On the label, look for a pH close to the vagina's own, which is slightly acidic, and a low osmolality, which just means less concentrated and kinder to dry skin. If something stings, try another.

2 more things help. Stopping smoking, because smoking makes your body clear oestrogen faster. And regular sexual activity, if you want it, helps blood flow to the tissue.

The free Vaginal and Bladder Health guide has a checklist, a 3-day bladder diary and the questions to ask.

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A good place to start:

Local oestrogen

Local (vaginal) oestrogen treats the cause: the low oestrogen in the tissue itself. National guidance recommends offering it, and using it for as long as it's needed.

It comes as a cream, a pessary (a small soft insert) or a small tablet you put into the vagina. It uses oestradiol or oestriol, and both are body-identical: the same molecules your own body makes. Very little of it reaches the rest of your body, so it's a different decision from full HRT (hormone replacement therapy), with different risks. At the usual doses you don't need a progestogen (the second hormone in full HRT that protects the womb lining) with it, even if you still have your womb.

Who it suits:

• Women already on HRT. It can usually be used alongside. A dose that settles hot flushes does not always reach these tissues, so many women need both.
• Women who only have these symptoms. It can be used on its own, without full HRT.
• Many women who can't take HRT, for example after a blood clot. It's decided case by case, on your own history.
• After breast cancer, national guidance puts moisturisers and lubricants first. In my view, breast cancer does not automatically rule local oestrogen out: the plan is made with your breast cancer team, often with body-identical vaginal oestriol. If you take an aromatase inhibitor (a type of hormone-blocking treatment), vaginal oestrogen is only used after a talk with that team.

It takes time. The tissue recovers gradually, over weeks to months, and symptoms tend to come back when it stops, so it's usually long term, with a review at around 3 months, then yearly. The leaflet in the box often carries the same warnings as full HRT. Please ask about it before you stop.

Some low-dose vaginal oestrogen can be bought from a pharmacy, after a chat with the pharmacist.

Your pelvic floor and your bladder

If you leak when you cough, laugh or exercise, pelvic floor exercises help most when you do them regularly for at least 3 months. A women's health physiotherapist can check you're squeezing the right muscles. Physiotherapy can also help when pain with sex has made the muscles tighten up in advance.

For urgency, needing to go more often and getting up at night, the evidence shows vaginal oestrogen can help too. Keep drinking normally, because concentrated wee irritates the bladder more. If caffeine, fizzy drinks or alcohol make the rush worse, try cutting down for 2 weeks. Keeping the Symptom Tracker alongside a 3-day bladder diary shows you the pattern.

When UTIs keep coming back

After the menopause, the changes in the vagina and the urethra (the tube you wee through) are one of the main reasons infections keep returning. There's good evidence that vaginal oestrogen means they come back less often.

Each infection needs a urine test and treating. If they keep coming back, ask for a urine culture, the lab test that grows the bacteria and checks which antibiotics work. If you had blood in your urine during an infection, it needs checking again once it's cleared.

Talk it through

This is a normal part of a menopause consultation. We go through your symptoms, your history and what you've already tried, then decide together what to start.

The Menopause Consultation is 45 minutes online, by video or voice call, wherever you live in the UK. You can book a Menopause Consultation here. For anything else, the Women's Health Consultation is the one for you.

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Debora Tentis, Women's Health Pharmacist.