Vaginal Atrophy: Why It Happens (and Why Topical Estrogen Is a Game-Changer)

Vaginal atrophy and dryness during perimenopause are more common than you think. Learn the symptoms, what helps (hello, topical estrogen), and how to talk to your doctor, without shame.

Let’s Talk About Vaginal Atrophy (Because No One Else Will)

You feel dry. Maybe itchy. Maybe sex hurts. Maybe you’ve started dreading even wiping after you pee.

And yet... no one mentioned this when they talked about perimenopause. There’s still a weird silence around what happens to our vulvas and vaginas when estrogen starts leaving the building. That silence? It’s hurting women.

Let’s change that, starting with what’s actually going on, what helps, and why you’re not alone (or broken).

What’s Actually Happening Down There?

When estrogen drops in perimenopause, one of the first places it disappears from is your vaginal tissue. Estrogen helps keep the vagina and vulva:

• Plump

• Elastic

• Moisturised

• Balanced in pH

• Protected from infection

  
  

As estrogen declines, the tissue:

• Becomes thinner

• Loses elasticity

• Dries out

• Feels fragile

• Is more prone to tearing, burning, infections, and pain

  
  

This is genitourinary syndrome of menopause (GSM) previously called vaginal atrophy. It affects up to 80% of women, but only a small percentage seek treatment. Why? Because we’re told it’s “just part of getting older.” It’s not. It’s preventable and treatable.

Dryness, Itching, UTIs and Painful Sex: It’s Not Just You

Here’s what vaginal atrophy can actually look like:

• Persistent dryness or “sandpaper” feeling

• Itching or irritation, especially at night

• Painful sex or even pain inserting a tampon

• Frequent UTIs or burning after sex

• Urinary urgency or discomfort

• A feeling like everything is “shrinking” or “closing in”

  
  

Sound familiar? You’re not making it up. These are all signs that your tissue is starving for estrogen, and you don’t have to live with it.

Bonus but Vital Section: What If It’s Not Just Dryness?

Let’s Talk About Lichen Sclerosus

If your symptoms include:

• Intense itching

• White patches

• Tearing of the vulvar skin

• Pain when peeing or wiping

• Skin fusing, shrinking or disappearing labia

  
  

...this could be lichen sclerosus (LS). It’s an autoimmune, inflammatory skin condition that can appear or flare in perimenopause, and it’s often mistaken for simple vaginal dryness or thrush.

Lichen sclerosus requires medical diagnosis and treatment, usually with a prescription steroid cream (like clobetasol). Left untreated, it can cause permanent scarring or, in rare cases, lead to cancer.

What to do if you suspect it:

• See your GP or a vulvar dermatologist (ask for a biopsy if the diagnosis isn’t clear)

• Don’t self-treat with over-the-counter creams

• Ask about long-term management and regular follow-up

  
  

Topical Estrogen 101: How It Works

Topical (or local) vaginal estrogen is not the same as HRT that you take orally or through the skin. It’s:

• Inserted directly into the vagina as a cream, tablet, or pessary (e.g. Ovestin, Vagifem)

• Restores elasticity, moisture, and healthy cell turnover

• Helps rebalance pH and reduce UTIs

• Usually used a few times a week long-term

• Can be used safely even in women with a history of breast cancer (under specialist care)

  
  

It’s not about sex appeal, it’s about basic comfort, bladder function, and quality of life.

“Is It Safe Though?” (Spoiler: Yes)

This is where the fear kicks in, usually thanks to the 2002 WHI Study, which scared the world off HRT for two decades. But:

• That study focused on oral systemic estrogen, not local vaginal estrogen

• Vaginal estrogen is minimally absorbed into the bloodstream

• It’s considered safe for long-term use, even for women over 65

• The cancer risk associated with topical estrogen is negligible or nonexistent in clinical reviews

The biggest risk? Doing nothing and letting vaginal atrophy worsen until basic things like sitting, walking, or intimacy are painful.

How to Ask for It (Without Feeling Awkward)

First, remind yourself: you’re asking for treatment for a medical condition, not a beauty treatment.

What to say to your GP:

“I’m experiencing dryness, discomfort, and frequent UTIs. I’d like to try topical estrogen to help restore vaginal health. Can we discuss that?”

If they’re dismissive or unsure, find a menopause-literate GP. Try:

• Jean Hailes Provider Directory

• Australasian Menopause Society

• Newson Health Directory (UK)

  
  

Other Tools That Help

While topical estrogen is the MVP, these sidekicks also matter:

Vaginal Moisturisers

Used regularly (not just during sex), they hydrate and repair. Look for:

• Yes VM

• Replens

• Olive & Bee balm

  
  

Lubricants

Water-based or silicone. Use them generously. Use them always. Try: Sylk, Uberlube, Yes WB, or even organic coconut oil (if not using condoms). (Avoid glycerin-heavy lubes: They can mess with vaginal flora and increase chances of thrush or irritation.)

Pelvic Floor Physiotherapy

If sex is painful or you feel tight and guarded, your pelvic floor may be holding tension. A women’s health physio can help a lot.

Final Word: This Is Not “Just Aging.” It’s Fixable.

You deserve to sit without wincing. To pee without burning. To enjoy intimacy without gritting your teeth. This isn’t vanity. This isn’t weakness. This is basic, preventable, quality-of-life care.

And the fact that no one told you sooner? That’s the real problem - not your vagina.

Join the Knew You Society to learn more, share your experience, and find your strength in community.

📚 References:

• Jean Hailes for Women’s Health: www.jeanhailes.org.au

• Australasian Menopause Society: www.menopause.org.au

• North American Menopause Society (NAMS): www.menopause.org

• Newson Health Menopause Society: www.newsonhealth.co.uk

• British Menopause Society: https://thebms.org.uk

• Lichen Sclerosus Support: LSA Australia

• NICE Guidelines on Urogenital Symptoms of Menopause