Perimenopause Vaginal Dryness: Treatment Options and What to Expect
What causes vaginal dryness in perimenopause, the full range of treatment options from local estrogen to moisturisers, and when to talk to your GP.
Genitourinary Syndrome of Menopause Explained
Vaginal dryness in perimenopause is part of a broader condition called genitourinary syndrome of menopause (GSM), a term that replaced the older label vulvovaginal atrophy. GSM captures the full range of symptoms that arise from estrogen decline affecting the vaginal and urinary tissues. Estrogen maintains the thickness, elasticity, and lubrication of vaginal tissues and supports the health of the urethra and bladder. When estrogen falls, vaginal walls thin and lose rugosity (the folded texture that allows stretch), lubrication decreases, pH rises (becoming less acidic and more prone to infections), and the urethra becomes shorter and more sensitive. Unlike hot flashes, which often resolve after menopause, GSM tends to worsen progressively without treatment and does not resolve on its own.
Symptoms of GSM Beyond Dryness
Dryness is the most well-known symptom of GSM, but the full picture is wider. Women commonly experience vaginal burning, irritation, and itching. Pain during sex (dyspareunia) ranges from mild discomfort to significant pain that prevents penetration. Post-coital bleeding can occur when fragile vaginal tissue tears. Urinary symptoms including frequency, urgency, burning on urination, and recurrent urinary tract infections are also part of GSM, because the urethral and bladder tissues share estrogen sensitivity with vaginal tissues. Many women attribute their recurrent UTIs to bad luck or hygiene rather than recognising GSM as the underlying cause, and treating GSM often substantially reduces UTI frequency.
Local Estrogen: Evidence and Safety
Local (vaginal) estrogen is the most effective treatment for GSM and has an excellent safety profile. Applied as a pessary, cream, or ring directly to the vaginal tissue, local estrogen works where it is needed with minimal systemic absorption. Because the dose entering the bloodstream is extremely low, local estrogen is considered safe for the vast majority of women, including many who have had breast cancer. Major oncology and menopause guidelines increasingly support its use in breast cancer survivors when symptoms significantly affect quality of life, following discussion with an oncologist. Local estrogen requires a prescription in the UK and most countries, but the conversation to obtain it is usually straightforward. Results typically become noticeable within four to twelve weeks of consistent use, and the treatment works best when continued long-term.
Non-Hormonal Options: Moisturisers and Lubricants
For women who prefer not to use estrogen or who want to manage symptoms between doses, non-hormonal options are available. Vaginal moisturisers, such as Replens or Yes VM, are applied regularly (every two to three days) rather than only during sex. They work by drawing moisture into vaginal tissues and are distinct from lubricants. Regular use reduces baseline dryness and discomfort. Lubricants are used at the time of sexual activity to reduce friction. Water-based and silicone-based lubricants are both effective. Oil-based lubricants should be avoided with latex condoms as they can cause breakage. Avoid lubricants containing glycerin, parabens, or fragrance, as these can cause irritation. Coconut oil and similar natural oils can work as lubricants for women not using condoms, but they are not recommended for internal vaginal use regularly as they may disrupt pH.
Products and Practices to Avoid
Certain common practices worsen vaginal dryness and GSM symptoms. Scented soaps, bubble baths, douches, and perfumed intimate wipes disrupt the vaginal microbiome and pH balance and cause further irritation. The vagina is self-cleaning and does not require internal washing. External cleaning with warm water only is sufficient. Synthetic underwear and tight clothing can increase heat and friction. Wearing breathable cotton underwear and avoiding tight waistbands reduces irritation. Smoking directly impairs tissue blood flow and worsens GSM by compounding the effects of estrogen decline on tissue health. Regular sexual activity or use of a dilator can help maintain vaginal elasticity and blood flow, which supports tissue health.
Systemic HRT and Its Effect on Vaginal Symptoms
Systemic HRT (patches, gels, tablets, or implants) raises circulating estrogen and improves GSM symptoms in many women. However, some women on systemic HRT still experience vaginal dryness and pain, because systemic estrogen does not always provide sufficient local tissue levels. In these cases, adding low-dose local vaginal estrogen alongside systemic HRT is safe, effective, and recommended by UK guidelines. The two approaches address different mechanisms and are complementary rather than duplicative. If you are on systemic HRT and still experiencing vaginal symptoms, this is worth raising with your GP or menopause specialist rather than assuming nothing further can be done.
Talking to Your GP About Vaginal Symptoms
GSM is one of the most undertreated perimenopausal conditions, largely because women feel embarrassed to raise vaginal symptoms with their doctors. Many GPs are receptive to the conversation and can prescribe local estrogen at the appointment. If your GP seems unfamiliar with GSM or dismisses your symptoms, asking for a referral to a menopause specialist or seeking a GP with a menopause interest is a reasonable next step. Logging your symptoms, their frequency, and their impact using an app like PeriPlan before your appointment helps you describe the full picture clearly and concisely, making the conversation more productive.
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