Article: A Letter to Your Perimenopausal Vagina
A Letter to Your Perimenopausal Vagina
I have to tell you something, girl. Because nobody else will.
Take a moment, think with your vagina, and make a plan.
When you were a young vagina, somebody told you you'd bleed regularly, and that if you weren't careful you'd get pregnant — or get an STD. Someone else told you about childbirth. And then perhaps you forgot all about it. You did it again and again — perhaps. But has anybody ever given you "the talk" about where your vagina is going from here?
Most likely not.
I'll admit I had some trepidation about having this chat. But I need to give you a little heads-up about where your 40-plus-year-old vagina is headed. I know she has her own bucket list: Machu Picchu, the Taj Mahal, opera at La Scala, Kilimanjaro. And for the vaginas who just want to stay home — the same is true. Hormonal changes are coming either way.
What to Expect From Your Expecting
Just as all our body parts change as we get older — a thickening of the waist, an occasional jowly look — our vagina goes through physiological changes too. Not to scare you, but the 70-year-old vagina actually has little in common with her younger sister, or her grandchild.
Older women's labia minora can actually disappear. That's not a figure of speech. The medical term for this whole constellation of changes is Genitourinary Syndrome of Menopause, and among its documented findings are thinning and resorption of the labia minora — in some cases the labia minora fuse into the labia majora entirely. In one survey of menopausal women, 37% reported that theirs had shrunk or disappeared.
I know some veterinarians who say that when dogs die, they just go to "Vermont" to frolic in the hills. Where do the disappearing labia minora of older women go? I have no idea. Maybe you'll write a short story about that.
As we get older, the frequency and severity of UTIs can also become an issue. And for those who have enjoyed sex and would like to keep that going, some precautions are worth taking.
So let's have the down-and-dirty girl talk nobody is having.
When Sex Starts to Hurt
Over the years, I've had a number of midlife women tell me that sex has become painful. Sometimes that pain predates midlife entirely.
Two different things get confused here, and the distinction matters when you go looking for help. Vulvodynia is chronic pain in the tissue of the vulva itself — burning, stinging, rawness — lasting three months or more. Penetration is usually possible, it's just miserable. Vaginismus is a different animal: the pelvic floor muscles clamp down involuntarily at the very prospect of penetration, so the opening — where a tampon or a penis goes in — is essentially closed for business.
For some women, that's lifelong. For others it shows up later, after enough bouts of painful sex.
The vagina is a smart thing
If painful intercourse continues, the vagina and its best friend, the brain, will squarely say, "This is no longer working for us!" And the vagina itself will begin to lock down and make such activity nearly impossible.
Our vaginas — and, more importantly, our brains — are designed for survival. If something is painful, we will do our best to avoid it.
For those of you who are hoping your sex life comes to a screaming halt in midlife, maybe this is a welcome time to get off that ride.
But for those of you who want to continue having an intimate life (and I apologize for any heteronormative language here), conversations need to happen with your partner. About the tools and substances needed. And probably about the fact that the incredibly athletic sex of your youth is, most likely, no longer on the menu.
Care and Keeping of Your Vagina
Many specialists believe that, like your face, your vagina needs constant moisture as you get older — one product more like a daily moisturizer, and a second, more lubricant-oriented one for penetrative sex. I've written about those two jobs and why you need both before, so I won't repeat myself here.
Why the moisture to begin with? With estrogen bottoming out, the vagina simply no longer makes appropriate lubrication of its own. Without it, sex can be quite problematic. The tissue inside the vagina also becomes thinner and more prone to tearing. Many doctors find that local use of estradiol helps prevent this — it comes as a cream or as a single-use suppository, to be used as your doctor directs.
There's a second reason to raise it with your doctor even if sex isn't on your list at all. In perimenopausal and postmenopausal women with recurrent UTIs, the American Urological Association guideline recommends vaginal estrogen therapy to reduce the risk of future infections, absent a contraindication.
Many women also find that the sensitivity of their clitoris, labia, and surrounding structures has become quite diminished. Some say, "it just feels dead down there." This is most likely a blood-flow issue — similar to what gets discussed with men and erectile or vascular dysfunction. Many doctors feel that sensitivity, too, can be improved with vaginal estradiol.
I've talked to thousands of clients and seen five menopause specialists myself.
Several of them prescribe something called Scream Cream — a compounded topical blend meant to bring blood flow to the area, for women who have a tough time reaching orgasm. It's worth knowing what it is and what it isn't: it's mixed at a compounding pharmacy rather than manufactured, there is no FDA-approved product for this use, and the published evidence on these blends is still thin. So go in with your eyes open and have the conversation with your doctor. If they haven't heard of it, feel free to try another doctor.
To be clear, I'm not dispensing medical advice. Everything described so far concerns the local use of supplemental hormones for staving off UTIs and preserving one's sex life. If you have had an estrogen-dependent cancer, triple-check every bit of this with your oncologist and your gynecologist before you do anything.
A note on what you put down there
We've touched on lubricants and moisturizers made specifically for the vagina. I am in no way suggesting you take your CeraVe and spread it to areas south.
One more note, for those who use vibrators. Oil-based lubricants — coconut oil included — are generally fine with high-quality, body-safe silicone, but they can degrade cheaper mystery-plastic toys over time. The bigger issue is condoms: oil breaks down latex fast and dramatically raises the chance of breakage. If condoms are part of your life, keep the coconut oil out of it and use water-based or silicone-based instead.
The Pelvis Nobody Checks
Another issue that comes up: a lot of women, believe it or not, have a hypertonic pelvis — meaning everything is too tight, locked down, closed for business.
Many of my clients go for pelvic floor physical therapy, with very good results. A systematic review in Sexual Medicine Reviews found that pelvic floor physical therapy improved muscle resting tone and reduced pain in nine of ten studies measuring it, including in women with painful sex.
OB-GYNs have historically prescribed dilators to "stretch everything out." I've watched many clients try that on its own over the years, and I believe pelvic PT does something far more integrative — the research tends to treat dilators as one tool inside a proper physical therapy program, alongside manual work, breathing, and relaxation training, rather than as the whole plan.
I'm honestly amazed by how happy my clients are with Dr. Allie Quick, PT, DPT, who runs Mae Physiotherapy just up the road in Middletown. Allie, can't wait to meet you — my people love you.
Where This Leaves You
Wishing you well on your journey. I hope you get the medical attention you need, and don't forget to advocate for yourself.
If your sex life is something you enjoy — including penetrative sex — as you get older, there will be some things you'll want to adjust. Namely:
- the vigorousness of your sexual encounters
- the need for supplemental moisturizers
- and, if it fits your worldview, hormone replacement — at the very least locally, for prevention of UTIs, for the sponginess of the skin, and for sensitivity
Are there acupuncture points and Chinese herbal medicine that can help with this? Yes. But do I suggest them in lieu of Western medicine? Personally, I don't. I think a combined approach is the sensible one.
Thank you again for your time and interest in this topic! If this post is a good fit for any of your friends, have them click here to subscribe to our free newsletter.
If you'd like the practical companion to this piece — what to buy, what to ask your doctor for, and how to have the conversation — I've put it in a free guide: Sex, Dryness and UTIs After 40.
Featured image: Utroba Cave — the "Womb Cave" — in the Eastern Rhodope Mountains of Bulgaria. The Thracians carved it around the 5th century BC, and historians believe they used it as a fertility shrine. Once a year in late winter, a shaft of light reaches the altar inside.
This information is for educational purposes only and is not a substitute for professional medical advice. Always consult a qualified healthcare provider before starting any hormone therapy, compounded medication, or treatment protocol — particularly if you have a history of estrogen-dependent cancer.
