Vaginal dryness — understanding, care and solutions

To understand why dryness develops, it helps to first understand how the vagina and the surrounding tissues work.

The vagina is an elastic muscular canal lined with a mucous membrane. Its moisture, elasticity and ability to resist irritation depend on several interconnected processes.

Natural moisture

Vaginal moisture comes from fluid that passes through the vaginal walls, as well as cervical mucus and other secretions.^[1] The amount can vary with hormone levels, the menstrual cycle and sexual arousal.

Elasticity and resilience of the mucosa

Oestrogens are a group of hormones that play an important role in the female reproductive system and in the health of various tissues. Oestradiol is the main oestrogen during the reproductive years. It helps maintain the thickness, elasticity, blood supply and natural moisture of the vaginal epithelium. When oestrogen levels fall, tissues may become thinner, drier and more sensitive to friction.

Vaginal microbiota

A variety of microorganisms live in the vagina. In many women, lactobacilli play an important role in maintaining an acidic vaginal environment and limiting the excessive growth of certain unwanted microorganisms.

These processes are closely connected. Hormonal changes can affect the mucosa, moisture and the vaginal microenvironment.

Maintaining intimate health is therefore about more than simply adding moisture.

Vaginal dryness does not have just one cause. It is often caused by a combination of factors.

Hormonal changes

Oestrogens help maintain the health of vaginal and vulval tissues.

When oestrogen levels fall, the mucosa may become thinner, less moist and less elastic, while the tissues become more sensitive to friction and irritation.

This can happen:

• During perimenopause — the transition before menopause, when hormone levels fluctuate.
• During and after menopause — when oestrogen levels remain lower.
• After childbirth and while breastfeeding — because of hormonal changes.
• After removal of the ovaries or certain treatments — if the body’s oestrogen supply is reduced.
• During some cancer treatments — if oestrogen production or activity is affected.

Medicines and health conditions

Some medicines, including certain antidepressants and hormonal contraceptives, may also contribute to dryness or mucosal irritation.

Certain illnesses can also have an effect, such as diabetes and Sjögren’s syndrome^[1] — an autoimmune condition that can cause dryness of the eyes, mouth and other mucous membranes.

If dryness appears after starting a new medicine or changes significantly without an obvious reason, it is worth discussing it with a doctor.

Stress, fatigue and everyday routines

Long-term stress, anxiety, lack of sleep, emotional strain and overwork can affect sexual arousal and natural lubrication.

However, two situations should be distinguished: when a woman is not sufficiently aroused, there may be less moisture at that particular moment; if dryness persists in everyday life, there may be another or an additional cause.

Scented intimate hygiene products, vaginal douching and other irritating products can also worsen dryness.

Simply resting more or changing one’s lifestyle is not always the solution. It is important to understand what is causing the symptoms.

The first signs may be mild, so they are not always immediately associated with vaginal dryness.

Pay attention to the following sensations:

• A feeling of dryness or tightness in or around the vagina.
• Burning, itching or tingling.
• Increased sensitivity and irritation.
• A feeling of friction when walking, exercising or wearing underwear.
• Discomfort or pain during intercourse.
• Insufficient natural lubrication during sexual intimacy.
• Small cracks or spotting after intercourse.
• More frequent urination or burning when urinating.

Not every woman will experience all of these signs. For some, dryness is the main problem; for others, it is burning, soreness or urinary symptoms.^[1]

Important: these signs are not specific to dryness. Infections, skin conditions and other health problems can cause similar symptoms.

New, pronounced or persistent symptoms require appropriate medical assessment.

Vaginal dryness is not always simply a lack of moisture. Sometimes it is a symptom of deeper changes in the tissues of the vagina and external genital area.

Vaginal atrophy is a term used to describe tissue changes often associated with falling oestrogen levels. Today, these changes are generally considered within the broader concept of genitourinary syndrome of menopause.

What happens in the body?

Oestrogen helps maintain the thickness, elasticity, blood supply and natural moisture of the vaginal mucosa. As oestrogen decreases, the mucosa may gradually become thinner and drier, tissues may lose elasticity and sensitivity to friction may increase.

The vaginal microbiota and pH can also change. In some women, the vaginal opening becomes less elastic and intercourse becomes painful or uncomfortable.

What are the symptoms of vaginal atrophy?

• Persistent dryness, tightness or burning.
• Itching and increased sensitivity.
• Pain or discomfort during intercourse.
• Small cracks or bleeding after friction.
• Sensitivity or a feeling of tightness at the vaginal opening.
• Urinary symptoms, such as burning when urinating or a more frequent need to urinate.

Changes can develop gradually, and symptoms may also appear several years after menopause.

Can vaginal atrophy be treated?

Yes. Several treatment options are available, and the choice depends on the symptoms and their cause.

Vaginal moisturisers are intended for regular use to help relieve dryness and maintain moisture. How often to use them depends on the specific product instructions and individual needs.

Local vaginal oestrogen can help reduce changes in vaginal tissues caused by oestrogen deficiency, improve the condition of the epithelium and relieve symptoms such as dryness, burning and pain during intercourse. Whether treatment is needed and for how long should be assessed individually with a doctor.^[2]

Moisturisers and lubricants help relieve symptoms. They do not replace oestrogen therapy or treat vaginal atrophy.

If symptoms persist or worsen, self-care products alone should not be relied upon.

Another problem that women are often reluctant to talk about is pelvic organ prolapse.

The uterus, bladder and rectum are located in a woman’s pelvis. The pelvic floor muscles, connective tissues and ligaments normally hold these organs in place.

If these supporting structures weaken or become damaged, one or more pelvic organs may descend below their usual anatomical position and bulge towards the vagina. In more severe cases, the bulge may reach or extend beyond the vaginal opening.

Why does it happen?

A combination of factors may contribute to prolapse:

• Pregnancy and childbirth, especially vaginal birth.
• Age-related changes in muscles and connective tissues.
• Hormonal changes during menopause.
• Long-term constipation and regular straining during bowel movements.
• Chronic coughing.
• Excess body weight.
• Repeated heavy lifting.
• Previous pelvic surgery and individual susceptibility.

Reduced oestrogen levels can affect the quality of urogenital tissues, but pelvic organ prolapse is primarily related to impaired support from the pelvic floor and connective tissues.

Vaginal dryness itself does not cause pelvic organ prolapse. Vaginal moisturisers do not treat or prevent pelvic organ prolapse.

How can you recognise pelvic organ prolapse?

Possible signs include:

• A feeling of heaviness, pressure or dragging in the pelvis or vagina.
• A sensation of a foreign body in the vagina.
• A bulge that can be felt or seen in the vagina or at its opening.
• Discomfort that worsens after standing for a long time or towards the end of the day.
• A feeling that the bladder does not empty completely.
• More frequent urination or urine leakage when coughing, sneezing or exercising.
• Constipation or difficulty emptying the bowel completely.
• Discomfort or changes in sensation during intercourse.

Symptoms depend on which organ has prolapsed and how pronounced the changes are. Prolapse does not always cause pain, and not every woman needs surgery.

Can prolapse be prevented or treated?

Some risk factors can be influenced, although complete prevention cannot be guaranteed.

Pelvic floor muscle exercises, guided by a physiotherapist when needed, preventing and treating constipation, treating chronic cough and adjusting physical activity may help.

If prolapse has already developed, treatment depends on its severity and the woman’s symptoms. Options may include pelvic floor physiotherapy, a vaginal support device called a pessary or, in some cases, surgery.^[1]

After menopause, a doctor may also recommend local oestrogen if there are symptoms of vaginal and vulval atrophy. It may improve the condition of the tissues and reduce discomfort, but it does not correct the prolapse itself.

During sexual arousal, blood flow to the genital area increases and natural lubrication becomes more pronounced. However, moisture produced during arousal is not the same as the moisture the mucosa needs in everyday life.

When the tissues are sufficiently moist and elastic, there is usually less friction. When the mucosa is dry and sensitive, friction may cause burning, pain and minor tissue damage.

Over time, a cycle can develop: a woman fears pain, which makes it harder to relax and become aroused, there may be even less moisture, and the next intimate encounter is uncomfortable again.

This does not mean she lacks desire for her partner or that her sexuality has ended. Physical discomfort can affect the desire for intimacy, and that is understandable.

Painful intercourse should not be accepted as normal.

Lubricant — important protection against friction and tissue damage

When vaginal dryness is present, using lubricant during intercourse is particularly important. It reduces friction between the vaginal mucosa and a partner’s penis or a sex toy, helps relieve discomfort and reduces the risk of minor mucosal injury.

If the mucosa is dry, thinner and more sensitive, friction can cause burning, small cracks and microtrauma. Sometimes this may also appear as slight bleeding after intercourse.

Do not wait until pain or burning begins. If you know you have vaginal dryness, use a suitable lubricant before intercourse^[1] and add more during intercourse if needed.

Choose a product intended for the intimate area and suitable for sensitive mucosa. Stop using it if it causes burning or irritation.

Remember: lubricant helps reduce friction and the risk of injury, but it does not treat vaginal atrophy or replace a doctor’s consultation if pain or bleeding recurs.

Vaginal health is related not only to moisture but also to the natural microenvironment.

During the reproductive years, the vaginal environment is usually acidic. Lactobacilli help maintain this environment by producing lactic acid. An acidic pH is one of the mechanisms that help limit the growth of certain unwanted microorganisms.

Glycogen is a carbohydrate stored in vaginal epithelial cells. Its breakdown products provide a source of nutrients for lactobacilli and help maintain the natural vaginal microenvironment. Lower oestrogen levels may reduce glycogen availability and decrease the proportion of lactobacilli.

Vaginal pH often rises after menopause because oestrogen has less influence on the vaginal epithelium and microenvironment.^[1] A higher pH alone does not indicate infection and should be assessed alongside symptoms and other clinical signs.

Likewise, a product containing lactic acid or lactobacilli is not a universal solution to all intimate problems. Treating dryness, bacterial vaginosis and a fungal infection are not the same thing.

When choosing an intimate care product, it is important to understand its intended use, ingredients and purpose.

There is no single vaginal dryness product that is best for every woman. The choice depends on the cause and severity of symptoms, the purpose of use and individual tolerance.

Vaginal moisturisers

Vaginal moisturisers are intended for regular use to help relieve dryness and maintain moisture. How often to use them depends on the specific product instructions and individual needs.

Vaginal moisturisers are intended for use inside the vagina. For external intimate care, choose a product intended for that purpose.

Moisturisers are one option for women seeking a non-hormonal approach. However, their effects and suitability vary, and they do not always address the underlying cause of symptoms.

Lubricants

Lubricants are intended to reduce friction during sexual activity.

Moisturisers and lubricants help relieve symptoms. They do not replace oestrogen therapy or treat vaginal atrophy.

When choosing a lubricant, consider its ingredients, tolerance by sensitive mucosa and compatibility with the condoms or sex toys being used.

Osmolality describes the amount of dissolved particles in a liquid per unit mass of solvent. Very high osmolality in intimate care products can adversely affect mucosal epithelial cells and increase the risk of irritation. When choosing lubricants or vaginal moisturisers, consider their osmolality, pH and how well the mucosa tolerates them.

Hormonal treatment

If dryness is caused by oestrogen deficiency, a doctor may recommend local vaginal oestrogen, for example as a cream, tablet or another suitable preparation.

Local vaginal oestrogen can help reduce changes in vaginal tissues caused by oestrogen deficiency, improve the condition of the epithelium and relieve symptoms such as dryness, burning and pain during intercourse. Whether treatment is needed and for how long should be assessed individually with a doctor.

Local vaginal oestrogen may also be considered for women using systemic hormone replacement therapy if genitourinary symptoms persist.^[1]

In some cases, systemic hormone replacement therapy is also considered, but the choice depends on overall health and other menopausal symptoms.

For women with a history of breast cancer or other hormone-sensitive conditions, treatment decisions should be made individually. Non-hormonal moisturisers and lubricants are usually tried first. If these do not provide enough relief, local vaginal oestrogen may be considered in some cases after weighing the benefits and risks with the treating doctor and, when needed, an oncologist.

Everyday intimate hygiene

Simple habits may also help reduce irritation:

• Avoid scented washing products and vaginal douching.
• Wash the external intimate area gently, without trying to wash inside the vagina.
• Do not use body or facial creams, oils or other products inside the vagina unless they are intended for that use.
• Use a suitable lubricant during intercourse if friction or discomfort occurs.
• Stop using any product that causes burning or irritation.

If symptoms persist, changing hygiene habits alone is not enough — the possible cause needs to be identified.

Regular, suitable intimate care can be important for a woman’s comfort, especially when dryness is associated with menopause or other hormonal changes.

A moisturiser may help maintain moisture, reduce friction and improve everyday comfort. However, it is important to understand its limits.

Moisturisers and lubricants help relieve symptoms.^[2] They do not replace oestrogen therapy or treat vaginal atrophy.

Vaginal moisturisers do not treat or prevent pelvic organ prolapse.

Why, then, is regular intimate care important?

Because it helps reduce discomfort, maintain mucosal moisture and notice changes in good time. If everyday care is not enough, a woman can seek more effective treatment promptly instead of accepting pain and irritation for years.

Caring for intimate health means more than relieving symptoms. It also means understanding your body and choosing an approach that fits your particular needs.

Intimate care products can help relieve certain symptoms, but they do not replace medical assessment when disease is suspected or symptoms persist.

A consultation with a gynaecologist or another appropriate healthcare professional is particularly important if:

• Dryness or irritation persists or interferes with everyday life.
• There is pronounced itching, burning or pain.
• Unusual discharge or an unpleasant odour appears.
• There is pain or burning when urinating, or recurring urinary tract infections.
• Cracks, sores or bleeding develop.
• Symptoms fail to improve or worsen after using self-care products.
• There is pressure or a bulge in the vagina that may suggest pelvic organ prolapse.

Any bleeding after menopause, including slight spotting, is a reason for medical assessment.^[2] Bleeding after intercourse should also be assessed.

These signs do not always indicate a serious illness, but they should not automatically be attributed to dryness or menopause.

Why is consulting a doctor so important?

Vaginal dryness can have different causes, and infections, skin conditions and other gynaecological problems can cause similar symptoms.

A doctor can assess symptoms, perform an appropriate examination and, if necessary, arrange further tests. This helps identify the most suitable approach — from everyday moisturising to specific treatment.

If a woman uses hormone replacement therapy but dryness persists, it is still worth discussing symptoms with a doctor. Changing the therapy is not always necessary, but additional local treatment or assessment of another cause may be needed.

Self-care and a doctor’s consultation are not opposites. They complement one another.