I have a question about the increase in yeast infections due to the drop in progesterone levels in perimenopause, and, if this is true, what is the recommended treatment? Also, I have heard about vaginal atrophy, which is a horrible, scary name, but I’m hoping you can explain it and give some hope for treatment.
—Dreading the discomfort of the years to come
Let’s start by agreeing on something. The term “vaginal atrophy” rivals “geriatric pregnancy” as the worst medical term of all time. Of course you are scared of “vaginal atrophy.” Who wouldn’t be? Wouldn’t “vaginal maturation” paint a much more appealing picture? But I digress.
Our hormones, both estrogen and progesterone, affect the lining of our vagina and vaginal secretions throughout our reproductive lives. Girls start having discharge when their bodies are preparing to ovulate and menstruate. If you were trying to conceive, you might have tracked cervical mucus to figure out when to have sex. When we go through menopause, our vagina changes again.
Estrogen is actually the more important player. When estrogen levels fall in menopause, vaginal secretions decrease, and the pH of the vaginal environment shifts. Women can experience vaginal dryness and discomfort. Over time, that dryness can cause the lining of the vagina to break down.
Changes in the vaginal lining and secretions from low estrogen can lead to a number of issues. The vaginal environment becomes less hospitable to healthy bacteria. This can allow more yeast to grow. It can also change the position of the urethra — the tube that carries urine from the bladder out of the body — leading to more urinary tract infections.
This all sounds very dire, but there is an easy solution that is safe for nearly all women: estrogen applied in the vagina. Estrogen applied as a cream, pill, vaginal suppository, or ring restores vaginal lubrication and pH and makes the vagina more hospitable to healthy bacteria. It also reduces the incidence of urinary tract infections.
Vaginal estrogen does not circulate in high levels systemically and, as a result, is considered safe for all women except those with a history of estrogen-sensitive tumors who are on estrogen blockers. The delivery mechanism does not seem to impact how effective vaginal estrogen is, so your preference is the most important factor. It is also safe to add vaginal estrogen to systemic hormone replacement therapy if estrogen taken through the skin or by mouth is not improving vaginal and urinary symptoms.
If vaginal estrogen is not an option for you, moisturizers formulated specifically for vaginal use, such as Replens, have been shown to relieve symptoms.
In short, vaginal atrophy is a significant problem for women in menopause. For most women, applying estrogen directly to the vagina is a safe and effective treatment.
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