Sex, vagina and bladder

Part 6 of 12 · All topics on the menopause

When the intimate area changes

Hot flushes are now talked about openly. Many women speak less often about burning, dryness, pain on touch or changed desire. Yet these symptoms in particular can be especially unpleasant: they affect intimate parts of the body, influence relationships and are sometimes linked with shame. Medically, they are by no means minor.

Some women notice increasing dryness, others a burning feeling when walking, cycling or having sex. Still others have to go to the toilet more often or have recurrent urinary tract infections. Such symptoms can partly belong to the genitourinary syndrome of menopause, abbreviated GSM. The term describes changes in the area of the vulva, vagina, urethra and bladder that can be linked to the hormonal transition. The syndrome can also become noticeable years after the last period, and without treatment it does not go away by itself in all women. [1] [2]

The word can is important: dryness or burning must not automatically be put down to oestrogen deficiency. Infections, skin conditions, irritants, pelvic floor disorders or side effects of medicines can cause similar symptoms. An examination can make sense, especially if pain is new, severe or recurrent.

Why local symptoms follow a different course from hot flushes

The lining of the vagina and the neighbouring tissues respond to hormonal changes. Among other things, moisture, tissue elasticity and the vaginal environment can be altered. Unlike vasomotor symptoms, which ease over time in many women, urogenital symptoms can persist or become stronger over the years. It is therefore worth raising them regardless of whether you still have hot flushes. [1]

A common mistaken belief is that pain during sex simply “goes with getting older”. This is not true. Pain is a signal to find out its cause. It can reduce desire, encourage avoidance of touch and in turn put a strain on the relationship. Often a cycle develops: one experience is painful, the next is anticipated with worry, and that makes relaxing harder. The right response is not to force yourself, but to take the pain seriously and look for treatment options.

Telling dryness, pain and infections apart

Dryness does not show itself only during sex. Some women notice friction during sport or discomfort in tight clothing. Others feel stinging, burning or itching. Not every itch is GSM: fungal infections, allergic reactions, lichen sclerosus or other skin conditions should be considered if the signs fit. A persistent whitish change in the skin, tears, sores or severe pain therefore belong in professional hands.

Vaginal discharge and odour can also have other causes. With new symptoms it helps to say openly what you feel – without first deciding whether it is “normal” or embarrassing. Good medical care asks about duration, location, symptoms when passing urine and during sex, changes in the skin and possible products that set it off. If needed, a gynaecological examination follows.

The bladder is sometimes affected too

Frequent urinary urgency, burning when passing urine, a sudden need to pass urine and recurrent urinary tract infections can occur in midlife. The causes, however, differ. A true bacterial urinary tract infection cannot be replaced by the term “menopause symptom”. With fever, pain in the flank, blood in the urine or a strong feeling of being unwell, rapid medical assessment is important.

For recurrent urinary tract infections, local vaginal oestrogen therapy can be an option for prevention in suitable postmenopausal women. This is a different question from the treatment of an acute infection. A current interdisciplinary American guideline on genitourinary syndrome is based on a broad review of the evidence and sees low-dose vaginal oestrogen as a particularly well-studied treatment option. The personal history – in particular hormone-dependent cancers – must be taken into account in the decision. [3]

Sexuality is more than a hormone curve

Sexual desire depends on physical well-being, mental state, relationship, experience, medicines, life situation and the personal meaning of sexuality. It is not equally strong in every woman, nor does it have to stay unchanged at every age. Anyone who feels less desire does not automatically have a disorder. It becomes relevant when the change is unwanted or causes distress.

Sometimes desire falls because sex has hurt. Sometimes it is exhaustion. Sometimes partners want different forms or frequencies of intimacy. And sometimes a woman experiences more sexual freedom than before, because worries about pregnancy lessen or she knows herself better. A credible guide must also leave room for this positive variety, instead of presenting sexuality only as a story of loss.

Research from Spain and Latin America shows that sexuality and quality of life are important dimensions of the menopause. Such studies broaden the view, but because of their designs and cultural contexts they do not allow simple comparisons along the lines that one nationality has “more symptoms” than another. [4] [5]

What helps with symptoms

For dryness or friction, suitable lubricants and regularly applied vaginal moisturisers can ease symptoms. For marked GSM, low-dose local oestrogens in particular come into question; they differ from systemic hormone therapy in their effect and in how much reaches the rest of the body. Which treatment makes sense depends on the findings, the symptoms, personal wishes and health history. A systematic review of 46 randomised trials showed differing benefits for various forms of local treatment, but also pointed to limited data for some long-term outcomes. [1]

With a history of breast cancer, the decision needs especially careful, where appropriate interdisciplinary, weighing up. The NICE guideline sees local oestrogens under certain conditions as a possible option after non-hormonal measures have been exhausted; during treatment with an aromatase inhibitor, oncology should be involved. Expressly, this does not lead to a blanket recommendation for self-treatment. The treatment details are summarised on the page Treatment without hormones. [6]

Starting a conversation without having to explain everything

It is enough to begin with a concrete sentence: “For some months it has burned during sex”, “I have recently had frequent urinary urgency” or “I would like to know whether my vaginal dryness can be treated.” If you find the examination unpleasant, you can say so. You may ask for explanations, a slower approach or a pause. Intimate symptoms do not have to become severe before they are taken seriously medically.

In a relationship too, a matter-of-fact sentence can change a lot: “Touch feels different at the moment. I would like to find out what is pleasant, and not to be under pressure.” For some couples, talking about other forms of closeness makes more sense than trying to carry on an earlier sexual routine unchanged. A change is not automatically a deficit.

A topic that many talk about too late

Dryness, burning or pain during sex are often raised only when they have already lasted a long time. Some women assume that such changes must go with getting older. Others fear that their symptoms are too private or too insignificant for a medical examination. Both are understandable, but can mean that problems that are easy to treat last for an unnecessarily long time. Genitourinary symptoms around the menopause affect the mucous membranes, vagina, outer genital area and, in part, the urinary tract. The symptoms can also appear for the first time, or more strongly, years after the last period.

The decline in the effect of oestrogen can make the tissue more vulnerable and drier. This does not lead to pain in every woman, but it is biologically plausible and clinically relevant. At the same time, not all symptoms in the intimate area are hormonal. Fungal infections, skin conditions, irritation from care products, pelvic floor tension or sexually transmitted infections also come into question. Recurrent burning or bleeding after sex deserves an examination, instead of being treated with products on the off chance. [1] [2]

Sexuality is not a duty and not a performance test

When intimacy becomes painful, more often changes than the body. Some women avoid touch because they expect pain. Their partner may interpret this as rejection. A physical difficulty that can be treated can thus turn into tension in the relationship. A helpful message is: pain is a reason to change what you are doing and to seek help, not a sign that you have to push yourself.

Sexual interest changes over a lifetime for many reasons. Alongside hormonal influences, there are the relationship situation, exhaustion, mental health, earlier experiences, medicines, body image and the quality of sexual encounters. It therefore makes little sense to explain libido solely by a blood value. For some women, lower desire is not in the foreground or is not experienced as a problem. A need for treatment arises above all when the change is felt as distressing and the person wants help.

The conversation can begin with a simple sentence: “For some time touch has felt different, and sometimes it hurts. I would like to understand what is behind it.” You do not need a perfect explanation and no justification. In good treatment, the type of pain, its location, possible inflammation and the situation during sex can also be discussed, without reducing the experience to a single hormone.

Moisturisers and lubricants are not the same

A lubricant is intended above all to reduce friction during a specific sexual activity. Vaginal moisturisers are used more regularly, to ease persistent dryness. That is a practical difference, even if the products look similar in advertising. Some women manage well with non-hormonal measures; others need more targeted treatment.

A systematic review of 46 randomised trials shows that vaginal oestrogens, vaginal DHEA preparations, ospemifene and moisturisers can improve certain symptoms in the short term. The quality of the evidence was often low, the studies differed considerably and long-term data were limited. On these pages that means: neither “everything works equally well” nor “only one single method helps”. Rather, it is explained which method was studied for which symptoms. [1]

The British NICE guideline recommends vaginal oestrogens for typical genitourinary symptoms and names non-hormonal moisturisers and lubricants as options if local oestrogens are not suitable or not wanted. Such recommendations do not automatically apply unchanged to every woman with certain cancers in her history; a specialised, shared decision may be needed there. [6]

When the bladder plays a part

Frequent urinary urgency, a sudden need to get to the toilet and recurrent urinary tract infections can greatly restrict quality of life. Some of these symptoms overlap with the genitourinary syndrome. Even so, they are not a clear “menopause signature”. Urinary tract infections, pelvic floor problems, overactive bladder, medicines or other illnesses can cause similar symptoms. Blood in the urine, fever, pain in the flank or severe pain should be assessed medically.

A common mistake is to treat urinary tract infections and urinary urgency as a single problem. An infection is diagnosed and treated differently from an overactive bladder. Recurrent symptoms therefore deserve a precise description: does it burn when you pass urine? Is the urgency sudden? Do you leak small amounts of urine when coughing or laughing? Is there a link in time with sex? Such details help in choosing suitable tests and treatments.

The pelvic floor can also contribute to symptoms – through weakness, but equally through increased tension. “More pelvic floor training” is therefore not a suitable universal answer. Especially with pain, a targeted examination or specialised physiotherapy can be more helpful than an indiscriminate exercise programme.

What changes after cancer treatment

Women with a history of breast cancer often face particularly difficult decisions about local hormonal therapies. Which option is possible depends, among other things, on the type of cancer, current medicines, the risk of recurrence and earlier treatments. The NICE guideline proposes an individualised weighing-up after non-hormonal measures have had insufficient effect and recommends involving specialist cancer care during treatment with an aromatase inhibitor. This is a good example of why a general guide can prepare medical decisions but cannot replace them. [6]

After surgery, birth injuries or in chronic skin conditions, other measures may also be needed. What matters is to understand the origin of the symptoms as well as possible and not to say “sign of ageing” too quickly.

What you can take to the appointment

Three questions can help: where exactly is the symptom? When does it occur? What has already been tried, and with what effect? You can also note whether dryness, burning, itching, pain on penetration, deep pain, infections or bladder problems are in the foreground. This makes an examination easier and prevents a complex problem from disappearing into a general category.

If you talk to a partner, clear boundaries can be useful: “This touch hurts at the moment; together we will find something that works well.” Sexuality does not have to take the same form in every stage of life to be fulfilling. The medical aim is less to force a supposed normal state than to ease symptoms and give back freedom to act. A good guide may offer this perspective without prescribing to any woman how often or in what way she should have sex.

Pain during sex follows different patterns

Not every pain during sex arises in the same place. Some women experience burning on first contact or at the vaginal entrance, others a deeper pain, still others a lasting unpleasant feeling afterwards. This distinction can be medically significant. It helps to check changes in the lining, infections, tension in the pelvic floor and other possible causes in a more targeted way. If the symptoms are new, recur or are linked with bleeding, an examination makes sense.

The same experience can also have psychological consequences. Someone who repeatedly experiences pain may become tense before touch has even begun. The tension can make the situation harder still. This does not mean that the pain is imagined. It can have physical and psychological components, both of which have to be taken seriously. Treatment can therefore include, alongside local medicines or moisturisers, specialised pelvic floor physiotherapy and sexual medicine counselling.

Recurrent urinary tract infections or just more frequent urgency?

The terms are easily confused, because both can go with frequent visits to the toilet. A urinary tract infection is an infection, whereas urgency can arise without an infection. Recurrent symptoms should therefore not be treated permanently with the same remedies on suspicion. Depending on the symptoms, a urine test, a medical history and further assessment can make sense.

With an overactive bladder, different questions are in the foreground from those with repeated bacterial infections: how often is the urge? Is there unwanted loss of urine? How much do you drink, and which medicines do you take? With certain symptoms, local treatment of the mucous membranes can help; other situations call for a targeted bladder or pelvic floor programme. There is no single plan for all women here.

The 2025 AUA/SUFU/AUGS guideline deals with genitourinary syndrome in detail. Its practical message is easy to sum up: symptoms should be asked about systematically, individual goals taken into account and local as well as non-hormonal treatments chosen with care. The guideline is a synthesis of existing research, not a new independent study of thousands of additional women. [3]

Conversations about intimacy do not have to be embarrassing

If you do not know how to start on a topic, you can choose a direct, matter-of-fact wording: “For some months I have had pain in the intimate area that I did not have before.” Or: “I wake at night because of urinary urgency. Can we discuss which causes come into question?” An exact account is more helpful than trying to translate the problem into medical language.

For conversations with a partner too, this applies: closeness and sexuality cannot be reduced to a question of frequency. Anyone who has pain may set boundaries. Anyone who feels less desire may say so without justifying it. And anyone who experiences a change as distressing may ask for treatment. The aim is not to restore a standardised sexuality, but a way of dealing with it that feels right for the person concerned.

The Spanish and Latin American research papers are a reminder that sexuality and quality of life cannot be studied only biologically. Norms, relationships and medical care influence whether symptoms are raised at all. This does not make subjective experiences any less medically relevant; it only helps to explain why figures and reports can differ from region to region. [4] [5]

When symptoms last beyond the menopause

Hot flushes decrease over time in many women. Genitourinary symptoms, by contrast, can persist or even appear only years later. This is an essential reason not to treat them as a short phase that one should in principle just sit out. Dryness, pain and recurrent irritation can affect well-being and sexuality in the long term. An early, matter-of-fact assessment can help to recognise other illnesses and to start suitable treatment. [1]

An example: a woman had hardly any symptoms during perimenopause and feels physically fit years after her last period. Even so, sex begins to become uncomfortable. She wonders whether this is a sign of lack of desire. In fact, local changes in the lining can play a part, even if there are otherwise no marked menopausal symptoms. It would not make sense to reduce her whole health to a question of hormones. Nor should she accept pain as unavoidable.

Diagnosis before treatment: why this is sometimes important

Itching, burning, pain and discharge can have various causes. A medical examination takes into account, among other things, the skin, mucous membranes, possible infections and the pelvic floor. Not all symptoms need an invasive examination straight away, but recurrent or unexplained symptoms in particular should not automatically be treated with over-the-counter products. If bleeding occurs after the menopause, a medical assessment is important.

Some women use particularly intensive intimate washing products because of an unpleasant smell or feeling. These can irritate sensitive skin further. The idea that the intimate area has to be constantly disinfected or perfumed makes no medical sense. Mild care that does not put unnecessary strain on the skin is often enough. With persistent symptoms, however, the right diagnosis is needed, not ever new care products.

Talking about local oestrogens in a matter-of-fact way

In contrast to systemic hormone therapies, local oestrogens are used specifically in the vaginal area. The doses used and the amount absorbed into the body differ from a treatment intended to act throughout the body against vasomotor symptoms. For genitourinary symptoms, the NICE guideline recommends local vaginal oestrogens in many situations and explains that serious side effects are rare. The individual history is nevertheless important, particularly with certain cancers. [6]

For a reader, it is crucial to understand that “hormones” is not a single concept here. A locally applied therapy for pain in the intimate area is not the same as a systemic treatment of night sweats. Anyone who only asks whether hormones are good or bad in principle may overlook this important distinction.

How long a local treatment makes sense and how it is monitored should be discussed with the healthcare professional treating you. In some women, symptoms return after stopping. This does not automatically mean that the treatment had made them “dependent”. It may simply show that the changes in the lining are still there. [6]

When non-hormonal products are preferred

Some women first want to use a moisturiser or lubricant. Such products can ease symptoms, especially dryness and friction. There are differences in ingredients, tolerability and use. If a product burns or irritates the skin, it is not automatically the right one. With persistent pain, the cause should be investigated, rather than just increasing the amount of the product.

The systematic review from 2024 shows possible short-term benefits of various local and non-hormonal options. The authors stressed, however, that the underlying studies were often short and used different criteria. The long-term safety with regard to rare events could therefore be judged only to a limited extent. This is exactly why practical recommendations are often more precise than advertising claims: a product can be a sensible option without answering all questions conclusively in scientific terms. [1]

The role of the relationship – without shifting responsibility

If sexuality was free of pain for years and now becomes uncomfortable, this can unsettle both partners. The woman affected may withdraw; the other person may misunderstand this. An open conversation can help, for example by naming pain and the closeness wanted separately. It is possible to seek physical tenderness and to avoid certain forms of sexual activity for the time being. Nobody has to endure pain in order to protect a relationship.

Medical care can treat physical causes. Couple or sex therapy counselling can additionally help if anxiety, communication problems or long-standing conflicts affect the situation. Neither approach automatically replaces the other. A woman with an infection does not first need a couples’ workshop; another, with chronic fear of painful sex, can benefit from psychological support alongside local therapy.

The pelvic floor as an often overlooked part

The pelvic floor is involved in continence, stability and sexual function. Symptoms do not arise only from supposed weakness. With pain, high muscle tension can also play a part. Generic calls to tense the muscles firmly as often as possible are therefore not sensible for all women. Depending on the findings, specialised pelvic floor physiotherapy can help to train the right coordination, relaxation or strength.

With recurrent pain in particular, an examination can help to distinguish whether touch irritates the lining, whether muscles tense involuntarily or whether there is another cause. Treatment should be guided by the findings. This may sound less spectacular than advertising for a universal intimate therapy, but it is usually the more appropriate route.

After cancer: especially careful shared decisions

Some of our readers have experienced a diagnosis of breast cancer or are still taking medicines that affect oestrogen metabolism. For these women, a general recommendation about vaginal hormones may not be enough. The decision depends on symptoms, the course so far, cancer treatment and individual risks. The NICE guideline recommends, in certain situations, in particular during treatment with an aromatase inhibitor, involving specialist cancer care. [6]

It is important not to rule out all help out of caution. Non-hormonal options can be a first step, and in certain situations further options are discussed after careful weighing up. The decision belongs in qualified care. A popular-science guide can prepare the questions, but cannot decide the treatment of a specific cancer history with a blanket sentence.

A kinder way of dealing with shame

Many women have learned to hide intimate symptoms. Perhaps even the word “vagina” sounds unfamiliar in a consultation. Yet these symptoms are neither a weakness nor a personal hygiene problem. They belong to medical topics that can be talked about matter-of-factly. An exact description often helps more than looking for the perfect technical term.

There is also no obligation to regard sexuality as a priority. Some women mainly want less burning when walking or passing urine, others sex without pain. Good treatment is guided by the person concerned. If she has no interest in a particular activity, resuming it is not a medical success that has to be forced.

What can be a sensible next step

If you notice such symptoms, choose the question that matters most to you. Does the pain occur in a particular place? Is dryness a nuisance outside sexual activity too? Is there frequent urinary urgency, signs of infection or bleeding? A short note can be helpful for the medical examination. On the pages Hormone therapy and Treatment without hormones you will find the main options with their limits, so that this page does not have to repeat all the treatment details.

The decisive point is this: symptoms in the intimate area can be treated, but they do not always have the same cause. Help begins with an open question about the cause and about your personal goal.