Vaginal dryness, painful sex, and recurrent urinary tract infections (UTIs) are symptoms that can show up in perimenopause that affects your day-to-day life.
Even though we used to think these kinds of symptoms happened only AFTER menopause ... but we know better now (thankfully!). These changes can happen wayyy before you have your final period ever.
Many women avoid intimacy, stop wearing jeans, and constantly worry about urinary leakage as they approach menopause--this is not okay!
Perimenopausal hormonal changes, especially decreasing estrogen, can affect vaginal, vulvar, and urinary tissue in many ways. Plus, your medical team might not be aware how soon these changes can start. This means that navigating these very real physical changes can leaves you feeling dismissed and confused. Trying to get science-backed answers about vulvovaginal health usually means wading through a mountain of shame, stigma, and outdated medical advice.
So, let's get into vulvovaginal health and the genitourinary changes that can happen in your 30s, 40s, and 50s as you navigate the hormone changes of perimenopause and beyond. Not everyone will get these symptoms, but we want to make sure you know what can happen and what to do about it.
For a long time, the medical community called these vaginal changes "vaginal atrophy." Thankfully, the terminology was updated to Genitourinary Syndrome of Menopause* (GSM). The most important distinction of this new name is the inclusion of the urinary system.
A better name would be Genitourinary Syndrome of the Menopause transition because it's not only when you reach menopause that you get symptoms.
When your estrogen levels decline during the menopause transition, the tissue changes (levels go up and down as you approach menopause, but the net change = decline). The skin gets thinner, more fragile, loses its elasticity, and gets drier.
Common symptoms of GSM include:
If you find yourself stuck in a cycle of returning UTIs, antibiotics, and doctor's visits, this can actually be a sign of GSM!
As estrogen goes down, the vaginal microbiome, the vulvar environment, and the urinary system fundamentally change. This shift leaves you far more susceptible to infection. Plus, there's reduced blood flow to the pelvic floor with lesser estrogen, which can contribute to urinary incontinence. More on that in this post about the pelvic floor.
Since the vagina and the bladder are so intimately connected (plus the openings are right beside each other), treating the hormonal decline locally can drastically improve your vulva, vaginal tract, and urinary symptoms.
Short answer: nope!
Some people can actually get these symptoms when they're breastfeeding or lactating because estrogen levels decline. We call this Genitourinary Syndrome of Lactation (GSL).
A lot of outdated literature suggests that GSM typically happens years after your last period, but as I mentioned earlier, many people experience these vaginal and urinary changes in perimenopause--well BEFORE they stop menstruating! This could be intermittently throughout the cycle, and it could also be cyclically (pay attention!).
Because of a massive practitioner education gap and perimenopause science gap, patients in their late 30s and 40s are often left out of the GSM conversation. If you don't feel like you belong in the perimenopause or menopause category yet, you might brush off your symptoms, thinking it must just be a random infection or random vulvar irritation. If you're experiencing changes, it totally could be hormonal even if/when you're having periods.
Vaginal moisturizers and vaginal hormone therapy are options for GSM. I'll break them down below.
Lubricant isn't a treatment option, it's more of an as-needed support to decrease friction.
While they both help with comfort, they do different things and should be used differently.
Vaginal Moisturizer: Exactly as it sounds, this is a treatment to increase your own tissue's hydration. It can be used daily, or can be used more frequently. Most moisturizers on the market will recommend using it daily for some time and then decreasing it to 2-3 times per week. A good vulvovaginal moisturizer is used regularly to treat dryness, soothe, and protect the skin.
A major ingredient studied for vaginal moisturizers is hyaluronic acid. As estrogen drops, we make less hyaluronic acid, which binds water and keeping tissue plump.
Lubricant (Lube): Lubricant is used as needed to reduce friction, whether that's for intimacy, pelvic physiotherapy, or tampon insertion. It doesn't actively treat or heal the underlying tissue dryness, but can really help increase pleasure and decrease discomfort when used.
Local vaginal estrogen is the gold standard for treating GSM, including the prevention of recurrent UTIs. It comes in creams, tablets, or rings, and it has an excellent safety profile.
Why is it so safe? Because it acts locally. It goes to work directly in the vulvovaginal and urinary tissues and does not circulate systemically throughout your entire body. This means it won't get rid of your hot flashes, but it also means it avoids the systemic risks and/or symptoms that may be associated with certain forms of systemic hormone therapy.
Unlike hot flashes, which may eventually resolve on their own, vaginal changes tend to get worse over time if left untreated. A standard protocol often looks like a daily loading dose for two weeks to rehydrate and saturate the tissue, followed by a maintenance dose of twice a week for the long haul. It can be super effective for preventing recurrent UTIs, rebuilding tissue strength, making intimacy more enjoyable, decreasing urinary leakage, and improving your overall quality of life!
Vaginal DHEA (brand name: Intrarosa(R)) can also be used for GSM.
This is not medical advice, but talk to your GP, OB/GYN, NP, or ND about local vaginal hormone therapy. If you're in Ontario, I prescribe this for patients (when appropriate, of course) and it's such a game changer! You can book in Innisfil, Newmarket, or virtually here.
Thank you to Dr. Dolores Fernandez, ND MSCP for inspiring this blog post. We recorded a great session on GSM, UTIs, and libido for The Perimenopause Summit coming up in Sept 2026--sign up here, it's free!.
References: Johnston S et al., Journal of Obstetrics and Gynaecology Canada, 2021. Danan et al., Ann Intern Med. 2024 PMID: 39250810.
