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Patient 1: “Dr. Kumar, I swear I cannot find my clitoris.”

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Patient 2: “My labia is shrinking!”

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Patient 3: “It’s the desert down there. You don’t understand.”

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Believe it or not, these are actual quotes from patients.

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At first, it was mostly about painful intercourse. There was vaginal dryness, often described as a “sticky lip.” To give you the full picture: imagine trying to wipe and searching where to place the toilet paper — but when you find the area, it’s hard to peel apart, and everything feels scratchy.

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Sounds familiar? Well YES! — it’s a real thing.  

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The Effects of Menopause in Your Genitals

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Genitourinary symptoms of menopause (GSM) occur when our pelvic organs experience a decrease in estrogen, which normally leads to:

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1. Changes in vaginal flora and pH
   
2. Regression of vaginal architecture (loss of shape)
   
3. Decreased moisture and sometimes tearing/injury (vaginal atrophy)
   
4. Loss of muscle tone (pelvic floor disorders)
   
5. Pain with intercourse (dyspareunia)

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Doesn’t sound like fun, right?  

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But do not worry — there ARE effective treatments, ranging from vaginal estrogen to hyaluronic acid and advanced lubricants.

Let’s dive in!

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Our Guide to Common GSM Treatments

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Intrarosa

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Intrarosa is ideal when vaginal dryness is combined with lower libido and decreased sensation. Prasterone, a natural steroid, converts to estrogen and androgens, decreasing atrophy, improving blood flow, reducing pain during intercourse, and enhancing sexual sensation. It takes 4–6 weeks to show results, as with all hormonal therapies.

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Intrarosa is inserted in the vagina with an applicator, but as I always remind patients, what goes up must come down: this means that after the medicine has been absorbed, the substances used to deliver the medication will come out.  

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Vaginal estrogen

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The powerhouse of treatments: vaginal estrogen cream treats symptoms of GSM, dryness, dyspareunia, recurrent UTIs, urgency, and mild incontinence. It restores normal vaginal pH, microflora, epithelial thickness and elasticity, as well as diminishing vaginal dryness. It may also help improve some bladder and urinary symptoms. Non-systemic and highly effective, it usually takes 4–6 weeks to reach its maximum effect.

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If you are using an estrogen patch, you can combine it with vaginal estrogen. The estrogen patch helps with systemic symptoms like hot flashes, night sweats, and mood swings, while the vaginal cream targets local vaginal and urinary symptoms. 

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Hyaluronic Acid

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Hyaluronic acid (HLA) traps moisture from our environment and brings it to the vaginal skin. It acts as a plumping agent and works well as a daily moisturizer without involving oils. I recommend it during the day after using estrogen or other medications in the vaginal canal, as it helps hold the medication against the skin.

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The most popular with FDA patents is a suppository called Bonafide. Replens Long-Lasting Moisturizer (comes in gel form) which also contains some HLA and targets the vulva, making it ideal for use with dilators.

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Imvexxy

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Imvexxy is an estradiol suppository recommended for deep vaginal burning or pain during intercourse. I sometimes use this alongside vaginal estrogen cream (one treats the vaginal canal, while the other treats the vulva).

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Lubricants

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When it comes to intercourse, Uberlube lasts longer than the water-based options. Coconut oil works in a pinch but can be messy, harder to wash off, and some patients do not like the sensation — however, it does work well for mixed oral and insertional sex.  

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Just remember: please AVOID heated, fragranced, or flavored lubricants to prevent vaginitis or allergic reactions.   

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Dilators 

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Vaginal dilators are smooth silicone devices used to gradually stretch and widen the vaginal canal, available in different sizes. Start with the smallest size, ideally in the shower or after bathing. You can leave it overnight, but make sure you are using a long-lasting lubricant or hyaluronic acid cream.

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‍Change to a bigger size every 2–3 days for more elastic tissue or weekly for severely affected tissue — but do not force it. Stimulating the area beforehand (with a vibrator or by yourself) helps relax the tissue and muscles.  

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Not sure where to start? I recommend this set from Amazon (affiliate link).

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A pelvic physical therapist can also help with pain with sex and use of the dilators. You can find one at Pelvic Rehab.

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Want help with your perimenopause symptoms? Book a 15-min FREE virtual consultation with us to see if we’re the right fit for your menopause care.

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And don’t forget to visit our Services page to explore our perimenopause and menopause care packages!

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