First the Facts

  • Female urogenital problems are common in association with lack of the hormone estrogen. This is most commonly due to the menopause, but it can also occur postnatally particularly in breastfeeding women and in association with certain methods of contraception and other gynaecological treatments
  • Up to 80% of postmenopausal women experience vaginal dryness, burning and itching during the menopause transition and beyond into the postmenopausal period
  • Only a small number of women with symptoms ask for help
  • Many women experience urinary problems in addition around this time
  • 50% of people over 70 years are sexually active, and this should be a time of sexual enjoyment and fulfilment (no risk of pregnancy!). Failure to consider the effect of estrogen deficiency on tissue quality and the influence that this has on sexual activity can have a negative impact on sexual activity in later life.

What You Need to Know: For People with a Vagina

Without the production of estrogen by the ovaries, the skin and supporting tissues of the vulva (‘lips’) and vagina become thin and less elastic. This is a common consequence of the menopause and the majority of women will experience some symptoms. Vaginal dryness is commonly the first reported symptom, due to a reduction in the production of normal vaginal secretions. Itching, burning and pain during sex are also commonly experienced.

Thinning of the tissues can also result in bleeding in association with sexual activity, especially if lubrication is also poor. For many people, sex becomes difficult, painful, infrequent or non-existent (even quite gentle friction can cause pain, discomfort and bleeding).

Without estrogen, the pH (acidity) within the vagina changes, due to a change in the balance of the micro-organisms. The normal discharge becomes more alkaline, which suppresses the levels of ‘good’ bacteria (lactobacillus), and this can lead to vulval and vaginal irritation.

Some people seek advice, but many do not ask for help. Because of this, relationships can suffer unnecessarily.

How Will I Know If I Am Experiencing the Effects of Lack of Estrogen Affecting Urogenital Tissue Quality?

Look out for any of the signs or symptoms listed above.

How Can I Protect Myself?

  1. Get help early.
  2. Have the right information before it is too late!
  3. Consider the following recommendations:
  • Avoid soaps to wash with (perhaps replacing with emollients (moisturizing creams), available from most pharmacies)
  • Treat underlying skin problems with topical preparations including ointments and creams, often after guidance by a specialist and perhaps a skin biopsy
  • Regular use of vaginal moisturisers and lubricants
  • Local estrogen therapy – it is now well recognised that low doses of estrogen therapy, delivered locally in the vagina, can be effective
  • There are various more recent treatments including ospemifene, which is taken orally on a daily basis, DHEA (dehydroepiandrosterone), a precursor hormone delivered vaginally on a daily basis and marketed as Intrarosa®, and laser therapy, at present available only in the private sector in the UK

When Should I See a Doctor or Nurse?

You should see a doctor or nurse if:

  • You are experiencing symptoms which could relate to lack of estrogen affecting tissue quality in the vulva, vagina or bladder
  • There is no definitive test, and the diagnosis is based on clinical findings
  • Treatments are effective and acceptable and unlike the conventional forms of hormone replacement therapy (HRT); effects are local, and therefore the risk of systemic side effects are reduced

Local Estrogen Therapy

Vaginal dryness, soreness, itching and burning usually respond to local estrogen treatments. These can also help to correct the vaginal pH and stop overgrowth of ‘unhealthy’ vaginal bacteria.

Estrogen delivered locally can be in the form of:

  • Vaginal tablets/pessary or a gel: initially used daily, then twice weekly
  • Creams: used daily initially, then twice weekly
  • Vaginal ring: silicone ring impregnated with estrogen changed 3-monthly

Selective Estrogen Receptor Modulator – Ospemifene

Tablet taken daily by mouth with a preferential effect on urogenital tissues.


A precursor hormone converted in the lining of the vagina to estrogen and testosterone with possibly an extra beneficial effect and minimal absorption into the blood stream.

Vaginal Laser Treatment

There are two types of laser, CO2 and erbium YAG (Er:YAG). Both stimulate cells which have the potential to create connective tissue, and this restores the urogenital tissues to how they were before the effects of hormone deficiency became established.

Pelvic Floor Changes and Prolapse Associated with Estrogen Deficiency

Postmenopausal women may become aware of bulging of the walls of the vagina, or of a feeling of ‘something coming down’. Others may experience a generalised dragging sensation ‘down below’. More than half of postmenopausal women are found to have some weakening of the vaginal walls or prolapse. The muscles and ligaments of the pelvic floor (which should normally support the womb, bladder and other organs) are also estrogen-sensitive, and changes in collagen, due to estrogen deficiency, can have a profound effect on the support mechanisms of the pelvic floor.

The protective covering of the clitoris may be affected by similar changes as those in the skin of the vulva and lining of the vagina. The clitoris can become exposed, sore and traumatised.

Lower Urinary Tract Symptoms

Many women may find that they have problems with their urinary tract (‘waterworks’).

Stress incontinence: leaking of urine on coughing, sneezing, running or jumping – this is likely to be due to a combination of factors including lack of estrogen and childbirth.

Urge incontinence: some people have difficulty ‘holding on’ once they sense that they need to empty their bladder, and they may leak urine before they can get to the toilet.

Other associated symptoms of overactive bladder include frequency (recurrent need to pass urine) and nocturia (need to pass urine at night leading to recurrent wakening) and the need to pass urine, despite having only just done so. These symptoms may be connected to overactivity of the bladder muscle in addition to lack of estrogen affecting tissue quality.

Recurrent urinary tract infections (UTIs): This is another form of ‘waterworks’ problem that affects people of all ages, but which increases in frequency with age.

Management of Urinary Problems

Local Estrogen

The role of local estrogen in the management of urinary problems is complex. Estrogen replacement therapy has been shown to alleviate urgency, urge incontinence, frequency, nocturia, and dysuria (discomfort on passing urine), and to reduce urine infections.

Genuine stress incontinence is not resolved by local estrogen therapy alone, but this does seem to add to the beneficial effect of other treatments.

Pelvic Floor Exercises

Other strategies involve pelvic floor exercises. Many women have learnt these techniques following childbirth, but it is well worth revisiting them. All women should do these exercises lifelong to strengthen the pelvic floor.

Pelvic-floor physiotherapists are specialists in this field. They are able to fully assess a woman’s pelvic floor function and teach appropriate techniques to strengthen it and train the bladder – they can then reassess and monitor improvements.


A ‘urodynamic’ assessment performed in a specialist clinic may be needed, but surgery only rarely is required, with minimally invasive techniques preferred.

Jargon Buster

  • Atrophic vaginitis – inflammation of vagina/vulva leading due to lack of estrogen – may cause discharge due to an overgrowth of ‘unhealthy’ bacteria
  • Cervix – the neck of the womb, at the top of the vagina
  • Dysuria – discomfort on passing urine
  • Dyspareunia – painful sex
  • Frequency – needing to pass urine often
  • HRT – hormone replacement therapy
  • Incontinence – involuntary leakage of urine
  • Local HRT – hormone replacement therapy applied directly to the vagina
  • Menopause – the last menstrual period
  • Nocturia – needing to pass urine at night leading to wakening
  • Perimenopause – the phase before the menopause takes place which can last from 5 to 15 years
  • Postmenopause – the time in a woman’s life after the menopause
  • Premature ovarian insufficiency/premature menopause – is when a woman goes through the menopause before the age of 40. The average age for the menopause is 51 years
  • Prolapse – collapse of the vaginal walls or descent of the uterus into the vagina
  • STI – sexually transmitted infection
  • Stress incontinence – leaking of urine when coughing, sneezing or laughing
  • Systemic – circulating throughout the whole body
  • Thrush (Candida albicans) – a fungal overgrowth especially in the vagina
  • Urethra – tube from bladder to outside through which urine is passed
  • Urgency – needing to pass urine urgently!
  • Urge incontinence – involuntary leakage accompanied by or immediately preceded by a strong desire to pass urine
  • Urodynamics – the study of pressure and flow relationships in the investigation of functional disorders of the lower urinary tract (LUT)
  • Uterus – womb
  • UTI – urinary tract infection
  • Vagina – genital canal leading to the uterus
  • Vaginal atrophy – drying and thinning of the vaginal and vulval skin
  • Vaginal flora – the micro-organisms in the vagina
  • Vulva – the external female genitals (lips)

Discussing Difficult Problems with a Healthcare Professional?

Top tips for discussing ‘embarrassing’ problems with a healthcare professional include:

  • Make a list of what you want to discuss
  • Discuss the most important or most difficult questions first
  • Write down what the doctor tells you
  • If there is anything that you do not understand, ask for clarification
  • If you feel embarrassed, take along some information with you. It can be difficult to discuss embarrassing problems face to face, but if you find information on the internet about your symptoms you can use this to help you explain and avoid having to make eye contact with your GP or nurse whilst discussing the problem
  • If you still feel unable to discuss the subject, write it all down and hand it to the doctor
  • Do not wait to be asked, give the doctor any information that you may feel is relevant, including a history of the condition, symptoms, the impact they are causing you, any lifestyle factors that may have contributed, any medication you are taking, etc.

Acknowledgement: Some of the information given in this post is based on the website of Women’s Health Concern (WHC), which is the patient arm of the British Menopause Society (BMS).


Written by: Dr Paula Briggs
Last updated: January 2021

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