What happens when hormones fall?
Falling oestrogen makes the vaginal lining thinner and less elastic, with less blood supply, a change in acidity, and less natural lubrication. The result is dryness, burning, itching, pain during sex, bleeding after sex, frequent or stinging urination, and recurrent urinary tract infections. Symptoms can begin before periods stop, and also in women who are breastfeeding or taking certain medications.
Level 1: no hormones
A vaginal moisturiser used regularly, 2–3 times a week, restores moisture over the longer term. This is different from a lubricant, which is used only during sex. Choose one without fragrance and with a pH close to the vagina's own. Water-based or silicone-based lubricants can be used alongside it. Regular sex or stimulation helps maintain blood flow.
Level 2: local hormones
Low-dose oestrogen as a cream, vaginal tablet or ring acts locally, with very little absorbed into the bloodstream. It works very well for dryness and pain within 4–12 weeks and reduces recurrent urinary tract infections. It is safe for most women, including many who have had breast cancer, although they should consult their treating doctor first.
Level 3: laser or RF
An option for women who cannot use hormones, do not want to, or find them not enough. It stimulates the lining to become thicker and moister without medication. 2–3 sessions, with results lasting a little over a year. If the lining is very thin, I may ask you to prepare with a local hormone cream first so the treatment is more comfortable.
Level 4: systemic hormone replacement
When there are other menopausal symptoms as well, such as hot flushes, poor sleep, mood swings or thinning bones, systemic hormone therapy helps all of them, including the vagina. The risk has to be assessed individually. Started within the first 10 years after the last period, the benefits outweigh the risks for most women, with regular follow-up.
How do you choose?
| If you | Start with |
|---|---|
| Have mild symptoms and prefer no medication | Moisturiser + lubricant |
| Have clear dryness and pain, no other symptoms | Local hormones |
| Cannot or do not want to use hormones | Laser/RF + moisturiser |
| Also have hot flushes or poor sleep | A discussion about systemic hormone replacement |
| Bleed after sex | A pelvic exam before anything else |
What needs checking first?
Any unusual bleeding after menopause needs its cause found before treatment starts. This includes a pelvic exam, up-to-date cervical screening, and a family history of breast cancer or blood clots. I do all of this at your first visit.
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