“It feels like razor blades.”
That’s how one of my patients described sex after menopause. Others say burning, tearing, ripping, stabbing.
And it’s not just during sex. Some women experience constant irritation—every time they wipe with toilet paper, put on jeans, or even wear underwear.
Others feel burning in the urethra that mimics a UTI, but no infection shows up. Or they start getting actual recurrent UTIs for the first time in their lives.
All of this from losing your period?
Yes. And here’s what makes me angry: Most women have never been told this would happen.
Up to 87% of women will experience these symptoms after menopause. But fewer than half have even heard of this condition, and even fewer have tried treatment.
This is a well-understood medical condition with safe, effective treatments. Yet women are left to suffer in silence because no one thought to tell them.
Let me give you the education you should have received: what happens to your vulva, vagina, and clitoris when estrogen disappears—and what you can do about it.
What Puberty Taught Us (And Didn’t)
To understand what happens after menopause, we need to start with puberty.
You probably learned about puberty in health class. Maybe you learned that girls develop breasts, pubic hair, and periods. Boys develop pubic hair too, and their testicles and penis grow.
What you probably didn’t learn: What happens to the vulva, vagina, and clitoris during puberty.
The textbooks don’t mention it. Your doctor probably never discussed it. So you likely never thought about it either.
But here’s what actually happens when estrogen arrives at puberty:
The labia thicken and grow. Vulvar skin may shift to darker pink and brown tones.
The clitoris lengthens and expands, becoming more visible—especially during arousal.
The vagina lengthens and becomes more flexible. The opening (introitus) widens. Secretions from the cervix and vagina increase, supporting lubrication and fertility.
The vaginal microbiome matures and stabilizes, helping fight off infections.
In short: The development of the vulva, vagina, and clitoris is a major event in puberty. It deserves to be recognized and celebrated, not ignored.
It’s Not Just Estrogen (But Mostly)
While estrogen drives most of these changes, other hormones matter too.
Testosterone plays an essential role in vulvovaginal health:
- Supports lubrication production
- Maintains sensitivity in the vaginal vestibule (opening)
- Supports clitoral blood flow, which affects pleasure and arousal
Without adequate testosterone, you can experience the same pain you’d get from low estrogen.
Progesterone is important for many aspects of women’s health, but it doesn’t appear to play a major role in vulvovaginal health.
The key point: Estrogen is necessary to develop and maintain the vulva, vagina, and clitoris. These tissues don’t just need a one-time dose at puberty—they require ongoing estrogen to function properly.
During your reproductive years, estrogen rises and falls with your menstrual cycle, but it’s always present at some level. When that cycle stops, estrogen drops to nearly nothing.
When Estrogen Disappears
Loss of estrogen doesn’t only happen at menopause.
Your period can stop due to:
- Menopause (natural aging)
- Breastfeeding (can last months to years)
- Gender-affirming hormone therapy (testosterone plus estrogen blockers)
- Extreme stress
- Cancer treatment
- Other illnesses
When estrogen goes away, the cellular machinery that was activated at puberty gets turned off.
Everyone experiences this differently, but the underlying process is the same. Here’s what can happen:
Physical Changes Without Estrogen:
Loss of cushioning: The tissue layer that provides padding under the vulvar and vaginal skin shrinks.
Loss of flexibility: The vaginal tissue that was pleated and stretchy becomes flat and rigid.
Loss of lubrication: Estrogen and testosterone support cervical and vaginal secretions. Without them, lubrication decreases dramatically.
Microbiome changes: Estrogen helps the vagina produce glycogen—food for beneficial lactobacillus bacteria. Without lactobacillus, the microbiome shifts and pH increases. This can change vaginal odor, which can be distressing.
Weaker pelvic floor muscles: Decreased strength contributes to urinary incontinence.
Smaller labia: Not a major problem for most, but it happens.
Smaller vaginal opening: The introitus doesn’t close completely, but even subtle narrowing and loss of flexibility can cause significant pain.
Urethral changes: The urethra becomes larger and more prominent. It can undergo changes that cause pain with urination. Combined with microbiome shifts, this can lead to increased UTIs.
Smaller, less sensitive clitoris: This affects arousal and orgasm. Women describe taking much longer to reach orgasm, or orgasms feeling weak or unsatisfying.
Why Sex Becomes Painful
With these changes, it’s easy to see why sex becomes painful:
- Less cushioning = more friction against bone
- Less flexibility = tissue can’t stretch to accommodate penetration
- Less lubrication = more friction against delicate tissue
- Smaller opening = even normal-sized objects cause tearing or burning
Women describe it as burning, ripping, tearing, or stabbing. Some find sex intolerable. Others experience constant irritation even without sexual activity.
This condition has a name: Genitourinary Syndrome of Menopause (GSM).
Up to 87% of women will experience some symptoms of GSM after menopause.
The Information Gap Is Unacceptable
This is a well-understood medical condition. Clear diagnostic and treatment guidelines exist.
And yet:
- Fewer than half of women have heard of GSM
- Even fewer have tried treatment
- Women suffer for years in silence
- Many stop having sex entirely because it’s too painful
Why?
Because the medical system doesn’t provide basic education about women’s bodies. Doctors don’t give women “anticipatory guidance” about what to expect or what they can do about it.
This isn’t a mystery or a rare condition. It’s a predictable part of aging for most women.
The failure to educate women about GSM is a systemic problem. It reflects how women’s sexual health is still deprioritized, dismissed, and ignored.
Here’s What You Need to Know
GSM is treatable.
There are safe, simple, and effective treatments that can restore vulvovaginal health and make sex comfortable again.
Treatment options include:
- Low-dose vaginal estrogen (creams, tablets, rings, suppositories)
- DHEA suppositories (hormone precursor converted to estrogen and testosterone)
- Vaginal moisturizers (non-hormonal option that can work as well as estrogen)
- High-quality lubricants (essential for comfortable sex)
- Pelvic floor physical therapy (for muscle-related pain)
For comprehensive information on treatment, read 5 Things You Can Do to Have Pain-Free Sex After Menopause.
For information on vaginal estrogen safety (including the FDA’s recent removal of the black box warning), read Is Vaginal Estrogen Safe?.
What You Can Do Right Now
If you’re experiencing painful sex, vaginal dryness, or urinary symptoms after menopause:
- Know this is normal and treatable. You’re not broken. This is a predictable result of hormonal changes.
- See a healthcare provider who can evaluate your symptoms and recommend treatment. Look for providers through:
- International Society for the Study of Women’s Sexual Health
- North American Menopause Society
- Your gynecologist or primary care provider (if they’re knowledgeable about GSM)
- Advocate for yourself. If your provider dismisses your symptoms or suggests you just “use more lube,” find someone else. GSM is real, it’s common, and it deserves proper treatment.
- Share this information. There are women in your life who don’t know about this. Tell a friend, a mother, a partner. We can close this knowledge gap together.
The Bottom Line
Every woman with a vulva and vagina should know what estrogen does for these tissues and what happens when it’s gone.
This information is basic to women’s health, sexual function, and quality of life.
The fact that most women don’t know about GSM until they’re already suffering is a failure of medical education and patient care.
You deserve:
- Information about how your body works
- Knowledge about what to expect as you age
- Access to safe, effective treatments
Women deserve better. And we can do better—by educating ourselves and each other.
Pass this on. Share it with someone who needs to know.
We can close this knowledge gap—one conversation about vulvovaginal health at a time.
Experiencing painful sex or other symptoms of GSM?
Sexual medicine consultations provide comprehensive evaluation and treatment for genitourinary syndrome of menopause. We’ll create a personalized plan to restore comfort and sexual function. Learn more about sexual medicine here.
For support navigating the physical and emotional aspects of sexual changes, sex counseling can help. Learn more about sex counseling here.
Dr. Lori Davis is a Doctor of Nursing Practice, board-certified Family Nurse Practitioner, and AASECT Certified Sex Counselor specializing in menopausal sexual health and genitourinary syndrome of menopause (GSM). She teaches sexuality counseling at the University of Michigan.
Note on language: In this article, terms like “woman/women” and “vagina/vulva” refer to anatomy rather than gender identity. This information applies to anyone with this anatomy, regardless of gender.
