Vaginal dryness, painful sex, recurring UTIs: The menopause changes women think they have to endure

Vaginal dryness that makes sex painful. Urinary tract infections (UTIs) that keep coming back. The anxiety of dealing with bladder leaks.

For many women, these symptoms of genitourinary syndrome of menopause (GSM) can affect daily routines and intimacy yet are often dismissed as something that comes with ageing.

GSM describes genital, sexual and urinary symptoms linked to declining oestrogen levels during and after menopause.

It has replaced some older terms, such as vaginal atrophy, vulvar atrophy and atrophic vaginitis, which do not cover urinary symptoms, said Dr Ho Ping Ling, obstetrician and gynaecologist at Ascensus Health in Mount Alvernia Hospital.

“(The term) ‘atrophic vaginitis’ wrongly suggested an infection while ‘atrophy’ carried negative connotations that made women reluctant to talk about it,” said Dr Ho.

Research shows that GSM affects approximately 65 per cent of women one year after menopause, rising to 84 per cent within six years, said Dr Ho.

Doctors say embarrassment, lack of awareness and the belief that nothing can be done lead women to put up with these symptoms rather than seek help.

“These symptoms may be common, but they need not be endured. No woman should feel that suffering in silence is simply part of growing older,” said Dr Ho.

A 2025 study by KK Women’s and Children’s Hospital (KKH), involving 1,461 women aged 45 to 65, found that vaginal dryness alone affects four in 10 women and is the fourth most common moderate to severe symptom during the menopause transition. Among those with moderate to severe menopausal symptoms, 70 per cent had not sought medical attention.

A separate survey of nearly 6,000 women aged 45 to 75 across Singapore, Taiwan, Indonesia, Malaysia and Thailand found that up to 57 per cent of women with GSM reported experiencing vaginal dryness while 43 per cent experienced irritation. Only one in four sought medical consultation.

WHAT FALLING OESTROGEN DOES TO VAGINAL TISSUES

As oestrogen levels fall during and after menopause, vaginal tissues can become thinner, drier, less elastic and more fragile.

This can cause irritation and small tears, said Dr Jean-Jasmin Lee, senior consultant at KK Menopause Centre and KKH Sexual Health Clinic.

These changes can affect the appearance of the vulva, the external genital area. For example, in more severe cases, the labia minora (the two inner folds of skin) may shrink or fuse together, said Dr Ho.

Such changes have prompted social media claims that a woman’s labia may “disappear” after menopause.

Dr Lee said that the claims are “not entirely wrong but they tend to dramatise what is a gradual and natural process”.

“Some women notice very little change, while others find the changes quite bothersome,” she said.

Not all changes to the vulva are due to menopause, Dr Lee added. Other skin conditions may cause similar symptoms, and it is worth seeing a doctor when there is persistent dryness, soreness, pain during sex, bleeding after sex, or any unusual skin changes.

HOW THE BLADDER AND URINARY TRACT ARE AFFECTED

Declining oestrogen levels can also affect the bladder and urinary system.

“Oestrogen serves as the vital architect of a healthy vaginal microbiome,” Dr Ho explained. “It sustains the protective flora that keep the environment safely acidic and highly resilient. In the absence of oestrogen, this harmonious balance shifts.

“The vagina becomes less acidic and loses much of its protective bacteria, which raises the risk of UTIs.”

Besides recurrent UTIs, many women find themselves needing to rush to the toilet urgently and frequently, waking up at night to urinate, and experiencing a burning sensation when passing urine, said Dr Lee.

“These symptoms can quietly but significantly disrupt daily life, affecting sleep, work, social activities and confidence,” she said.

WHEN SEX BECOMES UNCOMFORTABLE

For women with GSM, sexual intimacy can become uncomfortable or something they dread and avoid. In the KKH study, avoiding intimacy ranked as the sixth most reported moderate-to-severe concern.

“Pain during penetration can lead to anticipatory anxiety and increased pelvic floor tension. This creates a challenging cycle where anxiety reduces arousal and natural lubrication, making subsequent sexual activity even more painful,” she explained.

WHAT HAPPENS DURING A DOCTOR’S CONSULTATION?

Dr Ho said that GSM is not a temporary phase to “tough out” as it will only continue to deteriorate without intervention.

“Please know that doctors are very used to these conversations, and most women actually feel relieved once they do (bring up their concerns),” said Dr Lee.

Describing their experiences – symptoms, duration, how much it affects daily life – can help a doctor identify possible causes and discuss suitable treatment options.

Dr Lee emphasised that it is also useful to let the doctor know what products or medications they are currently using, as some products, such as scented soaps, douches or certain lubricants, can worsen symptoms.

“A gentle physical examination may be recommended to get a clearer picture, but your doctor will explain what they are doing and proceed at your pace. If an internal examination is needed, a smaller speculum may be used, or a lubricating gel applied to make it more comfortable,” said Dr Lee.

MANAGING GSM

According to Dr Lee, treatment decisions are based on the symptoms, how much they are bothering the woman, and not just on what the examination shows.

Vaginal moisturisers and lubricants may help relieve vaginal dryness and discomfort.

Lubricants are designed for relief of dryness during sexual activity, whereas moisturisers may maintain vaginal hydration for comfort and reduce symptoms, explained Dr Lee. They can be purchased over the counter at pharmacies.

When choosing products, Dr Lee suggested looking for those with a pH value between 3 and 5, and an osmolality (concentration) of 200 to 600 mOsm per kg to match the body’s natural chemistry. Products containing hyaluronic acid are particularly effective, said Dr Lee.

As many lubricant labels do not list their ingredients, Dr Lee suggested checking the manufacturer's website or product informational leaflet, or asking a pharmacist for guidance.

Avoid products containing parabens, chlorhexidine or polyquaternium-15, which may cause irritation, she said. Parabens are preservatives, chlorhexidine is an antiseptic and polyquaternium-15 is a synthetic conditioning ingredient.

For persistent symptoms, doctors may recommend vaginal oestrogen, which restores vaginal tissues, making them thicker, more elastic and generally better at producing natural moisture, said Dr Lee.

Vaginal oestrogen is available by prescription in different forms, including creams and small tablets (pessaries) that are inserted directly into the vagina, she added.

Regular, long-term use is often needed to maintain the benefits, as symptoms tend to return when treatment stops, added Dr Ho.

“As vaginal oestrogen comes in small doses, it does not increase the levels of oestrogen in other parts of the body very much,” said Dr Lee.

However, hormonal treatment is not suitable for everyone, and its risks and benefits should be assessed by a doctor based on each patient’s history.

“For women with a history of breast cancer or other hormone-sensitive cancers, low-dose vaginal oestrogen may still be an option worth discussing with their doctor. But seek a proper medical assessment first before using any oestrogen-containing product. Do not self-medicate,” said Dr Lee.

The encouraging news, said Dr Ho, is that vaginal tissues typically respond well to treatment at any stage. Starting treatment earlier, however, makes it easier to stay comfortable.

Lifestyle changes may ease discomfort although they cannot fully reverse oestrogen-related changes to vaginal tissues, the doctors said.

Women can use gentle, unscented products to clean the external genital area and avoid vaginal douching or scented washes that may cause irritation. Pelvic-floor physiotherapy may also help women who also experience pelvic-floor tension or related problems.

To manage bladder symptoms, women can adjust their fluid intake, such as drinking smaller amounts more frequently and limiting fluids before bedtime, as well as reducing caffeine and alcohol, which can irritate the bladder and may worsen urinary symptoms, said Dr Lee.

Bladder retraining exercises, a structured programme that teaches techniques to gradually increase bladder capacity and reduce urgency, may also help, she added.

WHAT ABOUT VAGINAL REJUVENATION LASER TREATMENTS?

Treatments marketed as ways to “rejuvenate” vaginal health, including vaginal laser or radiofrequency procedures, are currently not recommended. Most well-designed clinical trials looking at laser treatments have not shown meaningful benefit, said Dr Lee.

She warned of potential harms including burns and scarring, and advised being cautious of clinics that make bold promises without solid evidence to back them up.

“Major medical organisations, including the US Food and Drug Administration, the International Menopause Society and the American College of Obstetricians and Gynecologists, have all issued warnings advising against these treatments for GSM,” Dr Lee added.

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Source: CNA/pc