, Writer and editor, MyGLP. Sources checked .

What changes, and the name for it

Falling oestrogen changes the vagina, the vulva and the bladder. Doctors call the group of symptoms genitourinary syndrome of menopause, or GSM. The NHS menopause symptoms page lists:

  • vaginal dryness, burning, irritation or itching, which can make sex painful
  • more urinary tract infections (UTIs), or UTI-like pain or burning when you pee
  • needing to pee more often, including at night
  • urinary incontinence

The NHS adds that vaginal dryness may continue after the menopause, while flushes tend to settle. So these symptoms often get worse with time rather than better. Many women put up with them for years, assuming soreness is part of getting older. You do not have to.

Moisturisers and lubricants are different products

The NHS vaginal dryness page explains the difference.

Vaginal moisturiserLubricant
What it doesKeeps the vagina moist over timeReduces friction during sex
When you use itRegularly, inside the vagina, whether or not you have sexBefore or during sex
Where to get itPharmacies and shops, no prescription neededPharmacies and shops, no prescription needed
Points to checkChoose unperfumed productsWater-based types are safe with condoms. Oil-based types can damage them
Vaginal moisturisers and lubricants compared, from NHS guidance

The NHS also advises using unperfumed soaps around the vulva, avoiding douches and perfumed washes, and not using creams not made for the vagina. The NHS self-help page for menopause notes oil-based lubricants can damage condoms.

Vaginal oestrogen

When dryness comes from the menopause, the treatment that targets the cause is vaginal oestrogen. The NHS treatment page describes it as a cream or pessary used for vaginal dryness, soreness or urinary symptoms after the menopause. The NHS vaginal dryness page also lists gels and tablets.

The dose is low and stays mostly in the vaginal tissue. The NHS benefits and risks page says vaginal oestrogen does not increase the risk of breast cancer or blood clots, and because the dose is low it is considered safe for long-term use. You can use it on its own or alongside HRT patches, gels or tablets.

A commentary on the NICE guideline in BMJ Sexual and Reproductive Health summarises three more points from NICE. You can keep using vaginal oestrogen for as long as you need it, because symptoms often come back when you stop. You do not need routine checks of the womb lining. And you should report any unexpected bleeding.

Buying vaginal oestrogen from a pharmacy

In 2022 the MHRA made Gina 10 microgram vaginal tablets (estradiol) the first HRT product available in the UK without a prescription. The MHRA announcement sets the conditions:

  • you are aged 50 or over
  • you have not had a period for at least one year
  • a pharmacist checks the treatment is safe and suitable for you first

The tablets treat vaginal dryness, soreness, itching, burning and pain during sex caused by low oestrogen. If you are under 50, still having periods, or the pharmacist has concerns, you will need a GP or nurse to prescribe a vaginal oestrogen instead.

Repeat UTIs after the menopause

The NHS lists more frequent UTIs as a menopause symptom. NICE guideline NG112 on recurrent UTIs tells doctors to consider the lowest effective dose of vaginal oestrogen, for example estriol cream, for postmenopausal women with repeat UTIs, if hygiene and behaviour changes alone have not worked. NICE asks for a review within 12 months.

NICE also says HRT tablets should not be offered to reduce UTI risk. Vaginal oestrogen works locally where tablets do not.

After breast cancer

The British Menopause Society statement on HRT and breast cancer says vaginal moisturisers come first. If they do not help, low dose vaginal oestrogen can be discussed, because very little reaches the bloodstream. Vaginal oestrogen can be used with tamoxifen. With aromatase inhibitors such as letrozole or anastrozole it is generally not recommended, and any decision involves your breast team.

Sex, desire and the pelvic floor

Pain during sex can take desire with it. The British Menopause Society lists vaginal dryness among the causes of low desire to treat before anyone thinks about testosterone. If desire stays low once soreness has gone, read our testosterone guide.

Leaking when you cough, laugh or run is not something to live with. Pelvic floor exercises are the first treatment, and our pelvic floor guide shows how to do them.

Bladder changes beyond infection

The NHS lists needing to pee more often, including at night, and leaking among menopause symptoms. These are separate from infection. Write down how often you go, day and night, for three days before you see your GP or nurse. The record helps them tell an overactive bladder from leaks on coughing or exercise, because the treatments differ.

Questions to ask your GP, nurse or pharmacist

  • Is vaginal oestrogen suitable for me, and which form: tablet, pessary, cream, gel or ring?
  • Can I use it alongside my HRT?
  • How long before I notice a difference?
  • Would a referral to a pelvic health physiotherapist help my bladder symptoms?

Other causes of dryness to rule out

The NHS lists causes beyond the menopause: breastfeeding, some antidepressants and hormonal contraceptives, cancer treatment, diabetes and Sjogren's syndrome. If dryness started with a new medicine, ask your GP or pharmacist about it.

See a GP if dryness lasts more than a few weeks despite self-care, you have unusual discharge, or you have bleeding after sex, between periods or after the menopause. Any bleeding after 12 months without a period needs checking, even a single spot. Call 111 if you have a UTI with a high temperature, shivering or pain in your back or side.

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Sources

  1. Menopause and perimenopause: symptoms (NHS)
  2. Vaginal dryness (NHS)
  3. Menopause and perimenopause: treatment (NHS)
  4. Menopause and perimenopause: things you can do (NHS)
  5. Benefits and risks of HRT (NHS)
  6. Easier access to locally-applied HRT in landmark MHRA reclassification (MHRA, 2022)
  7. Urinary tract infection (recurrent): antimicrobial prescribing (NG112) (NICE)
  8. Commentary on the NICE menopause guideline (BMJ Sexual and Reproductive Health, 2016)
  9. BMS statement on testosterone (British Menopause Society, 2023)
  10. Benefits and risks of HRT before and after a breast cancer diagnosis (British Menopause Society)

Sian Anderson

Sian writes the health and nutrition guides on MyGLP. Every clinical claim links to the NHS, NICE, a medical royal college, a regulator or a peer-reviewed paper, and the pages carry no medical advice.