Ageing Down Under

Women are very aware of the effects of ageing on the skin, with countless products designed to prevent or hide the ‘signs of ageing’. What is often not recognised is the impact a woman’s age has on her genitals. As these changes are not as openly discussed, women often remain unaware of them. Genital changes are often met with a mixture of surprise and anxiety. Many women are too embarrassed to discuss the changes with their doctor and so often suffer the symptoms in silence. It is estimated that 10-40% of postmenopausal women experience symptoms related to vaginal atrophy (see vaginal changes section) but that only one quarter of these women seek medical help (1).

This article will examine the most common genital changes women experience with age, with a particular emphasis on vaginal atrophy.

Thinning/greying pubic hair

Like the hair on the head, pubic hair also tends to thin and grey with age. This is a natural process and, therefore, is not a cause for concern. For some women, however, the thinning of the pubic hair can be very disconcerting. Women may feel that their genitals are more exposed and visible. This is particularly relevant to women that may be feeling self-conscious about other changes that are occurring in the genital area (see vulval changes section). Women may also worry what their partner thinks of the changes. Women should refrain from dyeing grey pubic hair as the skin in the vulval area is extremely sensitive and can be irritated by the chemicals in the hair dye. If they do wish to dye their pubic hair they should use the services of a suitably qualified beauty salon.

Vulval changes

After the menopause, the drop in the female hormone oestrogen leads to a number of changes in the vulva. The connective tissues and fat deposits under the skin are reduced, resulting in the shrinkage of the vulva. For women this is often most noticeable in the appearance of the mons pubis (the pad of fatty tissue covered with pubic hair) which becomes less distinct. Similarly, the labia majora (outer lips) become less plump and more pendulous. The fold or hood of skin covering the clitoris may shrink and retract, giving the appearance that the clitoris is larger. The entrance to the vagina may also narrow (2). All of these changes, particularly those that are visible, can take time to adjust to. Women may find reassurance in knowing that these changes are normal signs of ageing.

Vaginal changes

The most significant ageing related genital changes for women are those associated with the vagina. A drop in oestrogen after the menopause causes the vagina itself to become narrower and shorter. The walls of the vagina become thinner and less elastic. There is also a drop in vaginal lubrication. Women commonly report symptoms of dryness, itching, burning and general discomfort. Vaginal atrophy is the term used to describe these changes.

In addition to day-to-day discomfort, vaginal atrophy can also impact on a woman’s sex life, with vaginal penetration being uncomfortable or even painful (referred to as dyspareunia). As the vaginal walls are thinner and less elastic, penetration can cause small tears, ulceration, bleeding and infection. If sex becomes uncomfortable or painful it can inhibit a woman’s ability to orgasm. If a woman no longer find sex enjoyable, it can quickly lead to a drop in sexual desire and/or the avoidance of sex.

The vagina also experiences a change in its pH level. The vagina normally has a pH level of between 3.8 and 4.5. Women with vaginal atrophy, however, have pH levels of between 6.0 and 7.5 (3). This more alkaline environment can increase a woman’s risk of opportunistic infections.

Treatment for vaginal symptoms

The first suggested ‘treatment’ recommended to women is to continue sexual activity. Sexual activity increases the blood flow to the genital area and this can improve lubrication and other symptoms. If women do not have a sexual partner, masturbation will achieve the same desired effect.

Non-hormonal vaginal lubricants and moisturises can also be helpful. There are a number of gels which are designed to assist with lubrication during sex (eg., KY gel, Sylk), temporarily reducing friction and making sex more comfortable. Other products act as a vaginal moisturiser and, therefore, aim to relieve the symptoms of vaginal atrophy such as itching, burning and general discomfort (eg., Replens). These products can be purchased from pharmacies (with lubricants also available from major supermarkets).

If non-hormonal products do not relieve symptoms, women can use local oestrogen (eg., cream/pessary). These products deliver a low dose of oestrogen directly through the wall of the vagina. Local oestrogen has been shown to restore normal pH levels and improve the elasticity and thickness of the vaginal tissue (4). Local oestrogen is only available on prescription.

Local oestrogen is not thought to have the same side effects and risks as systemic hormone replacement therapy (eg., tablets, patches). With systemic HRT, women who have a uterus must take both oestrogen and progestogen (oestrogen-only HRT in these women can increase the risk of endometrial cancer). Local oestrogen products, however, are generally considered to be safe to use short term without added progestogen. The North American Menopause Society’s position statement concludes that “[p]rogestogen is generally not indicated when low-dose estrogen is administered locally for vaginal atrophy … If a woman is at high risk of endometrial cancer, is using a greater dose of vaginal ET, or is having symptoms (spotting, breakthrough bleeding), closer surveillance may be required” (5). It is important, therefore, that women use local oestrogen products exactly as prescribed. Women with a history of hormone dependent cancers are advised that “management recommendations are dependent upon each woman’s preferences in consultation with her oncologist” (6).

If women are also experiencing other moderate to severe menopausal symptoms such as hot flushes, they may consider systemic HRT. It will provide relief from both the hot flushes and vaginal atrophy (local oestrogen will not relieve hot flushes). Women should discuss the risks and benefits of taking systemic HRT with their doctor.

Women who have found no relief with lubricants and vaginal moisturisers but who do not wish to use a hormonal product can try natural alternatives. Herbs such as nettle, comfrey root, dong quai, black cohosh, motherwort, chaste tree, witch hazel and wild yam are all used in treating vaginal symptoms, as are acidophilus capsules (7,8). There is, however, currently very limited evidence to suggest that these remedies are effective (9). There is some evidence that Vitamin E, either taken orally or applied locally is effective (10).

Phytoestrogens, naturally occurring compounds found in plants, are often reported as providing relief from menopausal symptoms. There is currently little evidence to suggest that phytoestrogens in either dietary intake or as a supplement will assist with vaginal atrophy (11).

Other popular treatments include bioidentical hormones. Bioidentical hormones are often considered by women to be a safer alternative to systemic HRT. However, there is currently limited scientific evidence supporting their efficacy and safety and, therefore, they should be considered as having the same risks as systemic HRT (12).

Vaginal atrophy and Pap smears

Women who have vaginal atrophy may find that it is reported on their Pap smear (as ‘atrophic vaginitis’). If the vaginal atrophy makes the smear too difficult to reliably interpret it is considered “unsatisfactory” and, therefore, needs to be repeated. In these cases, a woman’s doctor will generally prescribe a local oestrogen cream for a period of time before repeating the smear in three to six months. The use of a local oestrogen cream before having a Pap smear can also help to reduce some of the discomfort that women with vaginal atrophy often experience when having their Pap smear taken.

References

1 North American Menopause Society. The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society Menopause 2007; 14:3:357-355-69

2 Kelley C. Estrogen and its effect on vaginal atrophy in post-menopausal women Urol Nurs 2007; 27:1:40-45

3 Kightlinger RS. Vaginal atrophy: Clinical evaluation and management The Female Patient http://www.femalepatient.com/html/arc/sig/meno/articles/030_04_065.asp [website] date accessed: 27 July 2007

4 Cardozo L et al. Meta-analysis of estrogen therapy in the management of urogenital atrophy in postmenopausal women: Second report of the Hormone and Urogenital Therapy Committee Obstet Gynecol 1998; 92:4:722-727

5 North American Menopause Society. Ibid; 366

6 North American Menopause Society. Ibid; 367

7 Castelo-Branco, C. Management of post-menopausal vaginal atrophy and atrophic vaginitis Maturitas 2005; 52S:S46-S52

8 Willhite LA & O’Connell MB. Urogenital atrophy: Prevention and treatment Pharmacotherapy 2001; 21:4:464-480

9 Castelo-Branco, C. Ibid

10 Castelo-Branco, C. Ibid

11 Nedrow A. Complementary and alternative therapies for the management of menopause-related symptoms: A systematic evidence review Arch Intern Med 2006; 166:14:1453-1465

12 American College of Obstetricians and Gynecologists. No Scientific Evidence Supporting Effectiveness or Safety of Compounded Bioidentical Hormone Therapy ACOG news release 31 October 2005

Further help and information from Women's Health Queensland Wide

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This article was written by Kirsten Braun and reviewed by the Editorial Committee for Health Journey, Vol 3 2007.

Please note that this article is an archive. While every effort was made to ensure the information was accurate at the time of publication, the article has not been updated since this time. 

Last Modified: September 1, 2007