Sexual and pelvic health

Falling estrogen changes the tissues of the vagina, vulva and bladder, a condition called genitourinary syndrome of menopause (GSM). It can cause dryness, burning, pain with sex, urinary urgency and repeated bladder infections, and unlike hot flashes it usually gets worse over time without treatment. Desire often shifts too, for reasons that go beyond hormones. These problems are common, rarely discussed and very treatable.

Where to start

For the full picture of what falling estrogen does to these tissues and how it is treated, start with genitourinary syndrome of menopause. If dryness is the main issue, vaginal dryness treatments compares the options from moisturizers to vaginal estrogen. If sex has started to hurt, read painful sex in perimenopause, and if desire is the concern, low sex drive in perimenopause.

Common problems at a glance

Problem	What it feels like	What has evidence	Read the guide
Vaginal dryness	Dryness, burning or irritation day to day	Moisturizers and lubricants first; low-dose vaginal estrogen for moderate to severe symptoms	Vaginal dryness treatments
Painful sex	Pain at the entrance or deeper, often with muscle guarding	Treatment matched to the cause, including vaginal estrogen, DHEA, ospemifene and pelvic floor therapy	Painful sex in perimenopause
Low desire	Less interest in sex that bothers you	Fixing pain, sleep, mood and medication issues first; flibanserin; testosterone off-label after menopause	Low sex drive
Testosterone questions	Wondering whether low testosterone is the cause	Evidence only for postmenopausal women with diagnosed low-desire disorder; no FDA-approved product for women	Testosterone and libido
Recurrent UTIs	Two or more infections in six months, or three in a year	A urine culture each time; vaginal estrogen; cranberry; methenamine	Recurrent UTIs after 40
Bladder leaks	Leaking when you laugh, cough or exercise	Pelvic floor muscle training first; weight loss if overweight; devices or surgery if leaks persist	Stress incontinence

What the evidence says

Over-the-counter moisturizers, used two or three times a week, and lubricants, used at the time of sex, are first-line for mild symptoms; vaginal moisturizers and lubricants explains how to choose them. Low-dose vaginal estrogen has the strongest evidence for moderate to severe symptoms, and cream, tablet and ring forms work about equally well. Most treatments help within a few weeks, can take 12 weeks for full effect and stop working when you stop.

Pelvic floor physical therapy is the first-line treatment for stress incontinence: in trials, 56% of women who did pelvic floor muscle training reported cure, versus 6% without treatment. Trials also show benefit for prolapse symptoms, and a small trial found less pain with sex. Vaginal laser and radiofrequency treatments are not supported by current evidence, and supplements have not been shown to help dryness.

When to see a clinician

See a clinician if dryness, pain with sex or urinary symptoms are bothering you; an OB-GYN can examine you and rule out infection, skin conditions and other causes. Seek care promptly for a urinary infection with fever, back or side pain, or vomiting, and report any bleeding after menopause. The symptom check can help you raise these topics at the visit, and you can find an OB-GYN near you or browse the directory.