Not all symptoms of perimenopause, the yearslong lead-up to menopause, are as commonly discussed as, say, hot flashes and night sweats. What might catch you off guard is if your vulva starts to feel or look different—in color, shape, or even size.
Changing labia is just one symptom of what’s known as genitourinary syndrome of menopause, or GSM, Deidra Beshear, MD, an associate professor of internal medicine and medical director of the Women’s Health Clinic at the University of Kentucky HealthCare, tells SELF. GSM is a newish term, first introduced in 2014, to describe a range of vulvovaginal, sexual, and urinary tract symptoms that can happen when your estrogen levels start to decline in perimenopause.
Exactly when (and how quickly) these hormone changes unfold varies from person to person. The average age of menopause (which marks one year without a period) is 52 in the US, but perimenopause can start up to a decade earlier.
GSM often comes right along with it, affecting as many as 27% to 84% of menopausal women. Yet Dr. Beshear says many don’t discuss the symptoms with their doctors—only about 7% of women are receiving treatment for them. And in the absence of care, GSM doesn’t usually go away, but rather tends to get worse, Karen E. Adams, MD, an ob-gyn at the Stanford Health Care Gynecology Clinic and director of the Stanford Program in Menopause & Healthy Aging, tells SELF. Read on to learn more about the condition and the solutions that can reduce symptoms or even reverse its course.
How does genitourinary syndrome of menopause affect the vulva?
“The vagina loves estrogen,” Dr. Adams says. While it’s in ample supply, this hormone keeps that internal canal as well as your surrounding vulva (which encompasses your labia majora and minora) healthy, lubricated, and moist. Once perimenopause hits and estrogen begins to dip, “the vulvovaginal tissue becomes more fragile, prone to tearing, thinning, and dryness,” Angela Markman, MD, an ob-gyn at Women’s Health Specialists of CentraState, part of Atlantic Health System, tells SELF.
Over time, the tissue loses its fullness and elasticity. “If you look under the microscope at cross-sections of vaginal tissue from premenopausal women and postmenopausal women, you can see that the postmenopausal ones have many fewer cell layers,” Dr. Adams notes. That’s what causes the shrinkage you might notice in your vulva. Your labia minora, or the inner lips of your vulva, might also start to fuse together or become paler in color, Dr. Markman says. And the clitoral hood (the small piece of skin protecting the clitoris) can also get smaller.
Besides the aesthetic shift, these vulvar changes can be uncomfortable to deal with. The area may feel irritated or itchy, and its changing appearance might make you self-conscious or impact your body image, Jean Marino, APRN-CNP, a nurse practitioner at Kultivate Women’s Health, in Beachwood, Ohio, tells SELF.
What are the main symptoms of genitourinary syndrome of menopause?
Beyond causing visible changes to your vulva, the estrogen loss of perimenopause can make the lining of both your vagina and urinary tract thinner, drier, and less elastic. That can trigger many common symptoms of GSM.
Vaginal dryness, for instance, can make sex uncomfortable or painful, Dr. Markman says. Penetration could cause microtears, Dr. Adams says, which can lead to bleeding.
At the same time, the hormonal changes in the vagina can alter your vaginal pH and microbiome, allowing more bad bacteria to proliferate. Meanwhile, shrinking labia provide less of a protective barrier around the urethra, so those bacteria can easily get inside and cause a urinary tract infection (UTI), Dr. Adams explains. You could also experience UTI-like symptoms—needing to pee frequently or urgently, for instance—without actually having one, because of the changes in urinary tissue.
In sum, here are the typical GSM symptoms:
- Vaginal dryness
- Vaginal itching or irritation
- Decreased lubrication
- Pain or discomfort during sex
- Decreased libido
- Recurrent urinary tract infections
- Frequent need to urinate
- Pain or discomfort during urination
- Urinary incontinence
- Yellowish or whitish discharge
Plenty of these symptoms can have broader ramifications too. Pain with sex and low libido, for instance, could mean you have trouble getting aroused or having an orgasm, Marino says. And all of the above can damage your self-confidence, sex life, or relationship quality.
There can also be a “domino effect” leading to dysfunction of the pelvic floor, or that hammock of muscle supporting your pelvic organs, Dr. Adams says. “You start to anticipate pain with penetration, which causes the pelvic floor to spasm, often involuntarily,” she explains. That clenching can then cause even more pain with sex.
On the urinary side of things, recurrent UTIs can harm your health long-term, Dr. Beshear says. Besides being painful and a nuisance, they can lead to kidney problems, chronic bladder pain, resistance to antibiotics, or even life-threatening blood infections and sepsis.
What does treatment look like for GSM?
Whenever you notice vulvar, vaginal, or urinary tract changes, it’s important to see your ob-gyn or primary care doctor. They can do a pelvic exam and test your urine and vaginal pH to first confirm you’re dealing with GSM (and not another condition that causes vagina trouble). From there, they’ll walk through treatment options, which include the below.
Vaginal moisturizers and lubricants
These topicals are generally the first-line option because they’re cheap, available OTC, and very well-tolerated, Dr. Adams points out. The moisturizers contain hyaluronic acid—the same stuff that’s in face serums—to hydrate and plump up vaginal tissue, she explains. They come as gels that you swipe on or suppositories that you insert, generally three times a week. Dr. Adams says silicone lubricants are also ideal for minimizing friction and tearing during sex (so long as you’re not also using a condom or silicone sex toy, in which case water-based types are best).
Vaginal estrogen
The mainstay treatment for GSM is vaginal estrogen, Dr. Beshear says, to help restore the lost estrogen in this region. This can come in different forms, like creams and suppositories. “With these treatments, you can actually reverse the tissue thinning and grow more cell layers,” Dr. Adams says. It takes about six weeks to start seeing that benefit, and it gets progressively better with consistent application, she notes. (You have to keep up with regular use, for instance weekly, to keep things from reverting.)
If you have other menopause symptoms beyond GSM, such as hot flashes or night sweats, your doctor may recommend hormone therapy (HT), a form of estrogen that comes as a pill, patch, or gel. While vaginal estrogen stays local to the vagina, the estrogen in HT enters your bloodstream and travels to various organs and tissues that need it. (This is why people who can’t take HT—like those with breast or endometrial cancer, or a prior heart attack, stroke, or blood clot—can still use vaginal estrogen.) While HT usually relieves GSM symptoms, Dr. Beshear says some women don’t seem to get enough of the systemic estrogen in their vaginal tissues, so they choose to use vaginal estrogen as well.
Vaginal (DHEA) dehydroepiandrosterone
Like vaginal estrogen, DHEA (Intrarosa) is a hormonal suppository that only gets absorbed by the vaginal tissues—but it’s technically a different hormone that breaks down into several types of estrogen and testosterone, Dr. Adams explains. “It has similar efficacy for vaginal dryness and thinning as vaginal estrogen, and may offer additional benefits for sexual function, helping with desire and orgasm,” she says. But just note: It’s typically pricier and not as well-covered by insurance.
Pelvic floor physical therapy
If the ripple effects of GSM have left you with a tight pelvic floor, your doctor may suggest pelvic floor physical therapy, Dr. Adams notes. A therapist with expertise in this muscle region can help you unclench and learn to contract and release your pelvic floor without spasm, alleviating some of the pain with penetration. Pelvic floor PT can also combat the urinary leakage of GSM by improving your bladder control.
Ospemifene pills
There’s also an oral medication, called ospemifene (Osphena), that’s FDA-approved to treat vaginal dryness and painful sex in menopause. It’s a selective estrogen receptor modulator (SERM), which works by mimicking estrogen in the vaginal tissue. But because it brings similar benefits as vaginal estrogen, which is a lot cheaper, ospemifine isn’t well-covered by insurance. It could be a good choice for those with dexterity issues or anyone who can’t or doesn’t want to put something in their vagina, Dr. Adams says.
You might also hear about other medical interventions for GSM. Fractional CO2 lasers, for instance, purport to “create some of the changes at the cell level that let you grow new tissue,” but the benefits haven’t been shown to surpass those of vaginal estrogen—and some women can experience scarring from the lasers that causes more pain, Dr. Adams says. There are also at-home intravaginal red light wand devices. Research suggests they could boost blood flow to the area and help heal damaged tissue, but Dr. Adams notes that there haven’t been any high-quality trials to prove they work beyond a placebo.
What’s most important to know is, you don’t have to just live with vaginal and vulvar symptoms during perimenopause—the sooner you seek care, the quicker you can get access to the specific treatment that best fits your symptoms and lifestyle.
Related:
- 6 Common Behaviors Ob-Gyns Wish You’d Stop Doing
- Here’s How to Actually Clean Your Vagina
- 7 Women Share How They Find Relief From Perimenopause Symptoms
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