Why Vaginal and Urinary Symptoms Don’t Just Go Away After Menopause

For many women, the menopause transition is a time of total hormonal chaos. Fortunately, the wildly uncomfortable symptoms that often accompany this time of life, like hot flashes and night sweats, mood and memory changes, and sleep disruption, eventually improve and largely resolve once estrogen stops bouncing around like a manic chipmunk trying to remember where it buried its lunch.

Most symptoms, that is, except for urinary and vaginal symptoms.

These only get worse over time.

Well this is unfair. Why are our systemic symptoms ultimately pardoned by time but the vaginal dryness and urinary urgency seem to have their sentence prolonged indefinitely?

Because the role of estrogen in these tissues is different.

How Estrogen Affects Different Systems

Most of the disruptive symptoms of the menopause transition occur in response to hormonal fluctuations. For most women, when the hormonal fluctuations level out, even at a low or undetectable level, they feel more even, centered, and “back to themselves” again.

The vagina and the urinary tract are different. These tissues (which include the vulva, vagina, urethra, bladder, and pelvic floor musculature) are exquisitely hormone-sensitive and require estrogen to maintain lubrication, tissue elasticity, and a healthy microbiome.

Without it, the tissue becomes dry, thin, and susceptible to tearing and infection, which creates the common symptoms of vaginal dryness, painful intercourse, and a host of urinary symptoms from increased frequency and urgency to incontinence, prolapse, and frequent UTIs.

This constellation of symptoms are called the genitourinary syndrome of menopause.

So What Are We To Do?

First, mention these symptoms to your doctor! You do not need to suffer! While yes, these symptoms are common as women age, that does not mean that we need to resign ourselves to a lifetime of Poise pads and painful sex.

Many women don’t bring up sexual concerns to their doctors out of embarrassment or modesty, or an assumption that “this is just how it is.” Your genitourinary system plays an essential role in your whole body health and if your doctor doesn’t ask, bring it up yourself. Your doctor or health provider can’t help if they don’t know about it.

Next Steps and Treatment Options

Once you bring it up, you will hopefully be told about the many ways to address these symptoms.

First, if painful intercourse and vaginal dryness are a concern, you can try a lubricant (if you haven’t already). Most women pick up water-based lubricants at the pharmacy which, if you’re using condoms for pregnancy or prevention of a sexually transmitted infection, you must use, otherwise the condom could break down.

But if you are not in need of a barrier, consider a silicone or oil-based lubricant. Water based lubricants evaporate after a short time, so many women feel like they work at first, and then it becomes painful again. Although silicone and oil lubricants can be messy, they don’t evaporate and provide longer lasting lubrication.

Vaginal moisturizers are another great tool to try. Many are hyaluronic acid suppositories which rehydrate the tissue and can improve moisture and tissue elasticity. You can insert these suppositories 2-3 times a week, ideally at bedtime to minimize the amount of moisturizer coming back out.

There are also vulvar moisturizers that can be applied nightly to relieve external symptoms of itching, dryness, and irritation.

The Gold Standard: Local Vaginal Estrogen

The gold standard for the treatment of genitourinary symptoms is local vaginal estrogen therapy. This involves inserting either an estradiol cream or tablet into the vagina twice a week, typically.

This serves to replenish the estrogen in the vulvovaginal and urinary tissues and improves symptoms of dryness, painful intercourse, irritation, urinary urgency and frequency, and can reduce the risk of UTIs from 5 per year to 0.5 to 2 times per year.

In fact, a study done in 2024 demonstrated that the use of vaginal estrogen for all postmenopausal women would save Medicare between $6 and 22 billion dollars. UTIs cost Medicare almost $2 billion a year, accounting for office visits, urine cultures, antibiotics, and hospital and ICU admissions for sepsis.

With this statistic, vaginal estrogen therapy takes its place as a life saving and life prolonging treatment for women.

Is It Safe?

Vaginal estrogen is considered VERY safe. Since it is administered locally and at low doses, we do not have the same concerns about vaginal estrogen that we might have about systemic estrogen (meaning estrogen given as part of a hormone replacement therapy regimen).

It is safe for almost every patient, regardless of medical history. Of course you should discuss your specific case with your doctor, but there are truly only a small handful of conditions that should make us pause before prescribing vaginal estrogen.

Other Options to Discuss

There are other treatment options for local hormone therapy including a vaginal DHEA insert, an estrogen vaginal ring, and an oral medication that acts like estrogen in the vaginal tissue. These are all safe and effective treatments to discuss with your doctor.

Don’t Forget Pelvic Floor Physical Therapy

And finally, a pelvic floor physical therapist can be an essential part of your team that helps you through the menopause transition. A well trained pelvic floor therapist can assess for areas of weakness, tension, spasm, or imbalance and provide you with exercises uniquely tailored to you.

At Rhode Island Pelvic Wellness, we specialize in working with women in all stages of life, including perimenopause and postmenopause. Our care is one-on-one, trauma-informed, and highly personalized—no cookie-cutter routines here. We take time to understand your full story, including bladder, bowel, sexual health, and emotional well-being, to help you feel empowered and confident again.

We’re located in East Greenwich, Rhode Island, and you can learn more or book an appointment by visiting www.rhodeislandpelvicwellness.com or following us on Instagram @rhodeislandpelvicwellness.

Written by:

Erin Kunkel, MD, FACOG, DABOM, MSCP is a board-certified gynecologist specializing in menopause medicine and obesity medicine at Direct Doctors in East Greenwich, RI.
🔗 You can find her practice information here: https://www.directdoctors.org/womens-health.html

References

ACOG Practice Bulletin No. 141. Management of Menopausal Symptoms (Replaces Practice Bulletin Number 28, June 2001. Reaffirmed 2024)

Houston CG, Azar WS, Huang SS, Rubin R, Dorris CS, Sussman RD. A Cost Savings Analysis of Topical Estrogen Therapy in Urinary Tract Infection Prevention Among Postmenopausal Women. Urol Pract. 2024 Mar;11(2):257-266. doi: 10.1097/UPJ.0000000000000513. Epub 2023 Dec 28. PMID: 38154005.

Kaufman MR, Ackerman AL, Amin KA, Coffey M, Danan E, Faubion SS, et al. The AUA/SUFU/AUGS Guideline on Genitourinary Syndrome of Menopause. Journal of Urology [Internet]. [cited 2025 Jun 3];0(0). Available from: https://doi.org/10.1097/JU.0000000000004589