What does menopause do to the vagina?

The low estrogen levels of menopause affect a woman’s body in many areas and in many different ways. In the vagina, the low estrogen is associated with vaginal or vulvar dryness, discharge, itching and painful sex. At a cellular level, there is a thinning of the vaginal tissue which accounts for most symptoms that trouble women: vaginal dryness, irritation, itching, discharge, or pain with urination. Unlike the decrease of symptoms like hot flashes and night sweats, the vaginal changes do not eventually go away without treatment.

These changes are commonly called “vulvaginal atrophy (VVA)”. During a conference in May of 2013, the North American Menopause Society (NAMS) in conjunction with the International Society for the Study of Women’s Sexual Health (ISSWSH) created new terminology for these changes: Genitourinary syndrome of menopause (GSM). The new terminology includes a wider range of symptoms associated with menopause and was found to be more acceptable to the general public.

Regardless of the terminology, by 2025, we expect more than 1 billion women to be in menopause, the majority will likely be affected by GSM. The need for more and more diverse treatment options is pressing

How common are these problems?

This is a field that is growing in information every day. We now estimate that half of all women in menopause in the US have symptoms related to the vaginal changes that negatively affect their quality of life. This includes their comfort during routine daily activities, consequences to their sex life , effects on their marriage or relationships, and effects on their self-esteem. Most of them never proactively seek medical attention.

What options are out there?


The most common and oldest treatment is estrogen. Locally administered estrogen (tablets, creams, ring), is the primary treatment for complaints related to GSM. Different formulations of this estrogen have mostly been shown to be equal to one another and they all show improvement in both vaginal pain, irritation, painful sex as well as urinary issues like frequency, urgency, mild incontinence and recurrent UTIs. However, estrogen needs to be applied every day for sustained relief. There is also a small concern that even a low dose estrogen applied vaginally, when done so daily for years, may affect the uterine lining and increase the risk of uterine cancer. The WHI data caused the FDA to put a “black box” warning on all hormone use after menopause.


A newer, non-hormonal option is Ospemifene. An estrogen agonist and antagonist that selectively stimulates or inhibits estrogen receptors of different target tissues (SERM) was released in 2013. Taken as a daily tablet, Ospemifene slowly helps stimulate growth of the vaginal epithelium and by 3 months, patients are noting marked relief of symptoms. This drug has been studied in daily use for up to 52 weeks without any adverse effects on the endometrial lining or to breast health. While well tolerated, the most common complaints of patients taking Ospemifeneinclude vaginal discharge, muscle spasms, hot flashes and excessive sweating.

Vaginal lubricants and moisturizers

Women who are not interested in pharmaceutical treatments have long resorted to vaginal lubricants and moisturizers. Silicone-based or water-based vaginal lubricants and moisturizers can alleviate the symptoms of GSM. Lubricants are intended to relieve the friction and dyspareunia related to vaginal dryness during intercourse. Moisturizers are meant to help improve vaginal dryness, pH balance and elasticity.

An emerging therapy: fractional CO2 laser

The MonaLisa Touch was cleared by the FDA for use in September of 2014, for the treatment of various aspects of vaginal and urinary health. The device is a CO2 laser system that has been used and studied in Europe and Australia for some time. From a small metal probe, the laser rapidly supplies energy to the vaginal wall with a very specific pulse. This pattern of laser treatment helps ablate tissue that then causes the growth of new collagen and related components in the deeper layers of the vaginal wall.

Since the symptoms of GSM are related to the atrophy and poor blood flow that comes with menopause, this stimulation of new collagen growth results in new growth of capillaries and an increase in glycogen. As the pH stabilizes with this healthier vaginal wall, the bacteria living in the vagina remain in a better balance. These changes result in improved vaginal health as quickly as 2 weeks after the first treatment and maximize after the third treatment (performed at 6 week intervals). Patients note improvement in lubrication, comfort with sex, and bladder comfort and control while noticing less dryness, itching, infections and general irritation.

To date, more than 20,000 women worldwide with GSM have been treated with fractional CO2 laser therapy and the data has been very promising. Fractional CO2 laser has been used by dermatologists and plastic surgeons on the face, neck, and chest for decades without any known harm or long term adverse effects.

Treatment occurs in the office setting, without any anesthesia and is quite comfortable. The actual treatment lasts about 5 minutes, is performed every 6 weeks for three treatments. Generally a maintenance treatment is needed every 9-12 months to maintain the noted benefits.

We are quite excited to be able to provide this treatment option in our office. For more information on the MonaLisa touch, you can learn about it on our website or contact Shar at 650-396-8110 or Shar@elcaminowomen.com to ask questions or book a consultation.

Disclaimer: There is no financial relationship between any of the physicians or staff at El Camino Women’s Medical Group with the makers of Ospemifene or the MonaLisa Touch.

 The MonaLisa Touch treatment is available at El Camino Women’s Medical Group.   Call the office (650-396-8110) or email Shar (Shar@ElCaminoWomen.com) for more information.

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Includes explanation of the genitourinary syndrome of menopause (GSM) as well as our comprehensive chart of available treatment options, from doing nothing, to over the counter options and prescription medications.

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