Vaginal Dryness: Causes and Treatment

Symptoms

• Dryness, itching or burning in the vagina or vulva
• Pain, rubbing or tearing during sex (dyspareunia), sometimes with light bleeding afterward
• Soreness when sitting, walking or wearing tight clothes
• Light discharge or a change in vaginal odor
• Needing to urinate urgently or often, burning on urination and repeated urinary infections
• Reduced desire and arousal because sex is uncomfortable

Because the vagina, urethra and bladder share estrogen-sensitive tissue, doctors now use the term genitourinary syndrome of menopause (GSM) for the combined vaginal and urinary symptoms.

What causes vaginal dryness

Low estrogen

Estrogen keeps the vaginal lining thick, elastic, moist and slightly acidic, which supports protective lactobacilli bacteria. When estrogen falls, the lining thins, produces less moisture and becomes more fragile. Causes of low estrogen:

• Menopause and perimenopause: the most common cause
• Surgical menopause after removal of both ovaries, which causes sudden symptoms
• Early menopause or premature ovarian insufficiency
• Breastfeeding and the months after childbirth
• Cancer treatment: chemotherapy, pelvic radiotherapy, and hormone therapy for breast cancer such as aromatase inhibitors and tamoxifen
• Medicines that suppress estrogen for endometriosis or fibroids
• Very low body weight, eating disorders and excessive exercise, which can stop periods

Medicines and products

• Antihistamines and decongestants, which dry mucous membranes
• Some antidepressants, which can reduce arousal
• Low-estrogen birth control pills, and some other hormonal contraceptives
• Douching, scented soaps, bubble baths, wipes and spermicides

Other causes

• Low arousal: not enough time or stimulation before sex, relationship stress, anxiety or pain
• Sjögren's syndrome: an autoimmune disease causing dry eyes, dry mouth and vaginal dryness
• Diabetes, which affects blood vessels and nerves
• Smoking, which reduces blood flow and estrogen effects
• Skin conditions such as lichen sclerosus and lichen planus, which cause soreness and scarring

Vaginal dryness in your 20s and 30s

Younger women most often notice dryness from hormonal contraception, breastfeeding, antihistamines, antidepressants, stress, low arousal, intensive exercise or low body weight, and irritating hygiene products. Premature ovarian insufficiency, with irregular or absent periods and hot flashes, is a less common but important cause to check.

When dryness may be something else

Itching and burning can also come from a yeast infection, bacterial vaginosis, sexually transmitted infections, contact dermatitis and lichen sclerosus. A doctor can tell these apart by examination and simple swabs.

Diagnosis

Diagnosis is usually based on your symptoms and a pelvic examination, which shows pale, thin, dry tissue with fewer folds. The doctor may check vaginal pH (higher than normal after menopause), take swabs to exclude infection, and test urine if you have urinary symptoms. Blood hormone tests are not usually needed after age 45.

Treatment for vaginal dryness

Without hormones

• Vaginal moisturizers: used 2 to 3 times a week regardless of sex, they rehydrate the tissue. Hyaluronic acid products are an option.
• Lubricants: used during sex. Water-based and silicone-based lubricants are safe with condoms. Oil-based products can damage latex condoms.
• Avoid irritants: no douching, scented products or harsh soaps; wash the vulva with water only.
• Regular sexual activity or vaginal stimulation helps maintain blood flow and elasticity.
• Pelvic floor physical therapy helps pain and muscle tightness during sex.
• Vaginal dilators if the vagina has narrowed, for example after radiotherapy.

With hormones

• Low-dose vaginal estrogen as a cream, tablet, insert or ring is the most effective treatment for menopause-related dryness. Very little is absorbed into the bloodstream, and it does not carry the risks of systemic hormone therapy. It also reduces urinary urgency and repeated UTIs. Improvement usually starts within a few weeks, and treatment is long term.
• Vaginal DHEA (prasterone) inserts.
• Ospemifene, a tablet that acts like estrogen on vaginal tissue.
• Systemic hormone therapy helps if you also have hot flashes, though some people still need vaginal treatment.

If you have had breast cancer, talk with your oncologist. Non-hormonal products come first, but low-dose vaginal estrogen may be considered in some situations.

Frequently asked questions

What causes vaginal dryness?

The most common cause is low estrogen around and after menopause. Breastfeeding, cancer treatments, some contraceptives, antihistamines, antidepressants, douching and scented products, low arousal, Sjögren's syndrome and smoking can also cause it.

What is the best treatment for vaginal dryness after menopause?

Low-dose vaginal estrogen is the most effective treatment and is considered safe for most women, with minimal absorption. Regular vaginal moisturizers and lubricants for sex help too. Vaginal DHEA and ospemifene are other prescription options.

Can young women have vaginal dryness?

Yes. In younger women, common causes include hormonal birth control, breastfeeding, antihistamines, antidepressants, stress, low arousal, intense exercise, low body weight and irritating soaps or douches. Absent or irregular periods with dryness should be checked for early ovarian insufficiency.

Does vaginal dryness go away on its own?

Dryness from breastfeeding, a medicine or a temporary cause often improves once the cause ends. Dryness from menopause usually does not go away and tends to worsen over time, but it responds well to treatment with moisturizers and vaginal estrogen.

Is vaginal dryness linked to urinary problems?

Yes. Low estrogen also thins the urethra and bladder lining, causing urgency, frequency, burning and repeated urinary infections after menopause. This is why doctors call it the genitourinary syndrome of menopause. Vaginal estrogen improves these urinary symptoms too.