Vaginal and Urinary Changes — What Partners Should Know

Genitourinary syndrome of menopause (GSM) is the current medical term for the constellation of vaginal, vulvar, and urinary symptoms caused by declining estrogen. It replaces older terms like 'vaginal atrophy' and 'atrophic vaginitis,' which were both clinically limiting and off-putting. GSM encompasses: vaginal dryness, burning, and irritation; loss of vaginal elasticity and tissue thinning; pain during intercourse (dyspareunia); reduced natural lubrication during arousal; urinary urgency, frequency, and recurrent UTIs; and changes to the external vulvar tissue. Over 50% of postmenopausal women experience GSM, though many experts believe the true prevalence exceeds 70% because it's severely underreported. The critical difference between GSM and other menopausal symptoms is that it's progressive. Hot flashes tend to improve over time. GSM gets worse. Without estrogen, vaginal and urinary tissue continue to thin, dry, and lose function. The vaginal pH changes, disrupting the protective microbiome and increasing susceptibility to infections. Blood flow decreases, reducing tissue health and healing capacity. Many women don't mention these symptoms to their partner or doctor because of embarrassment, the belief that it's 'just aging,' or resignation that nothing can be done. All of those beliefs are wrong, and your gentle awareness can help bridge the gap.

GSM can profoundly change the sexual experience for her, and by extension, for both of you. When vaginal tissue is thin and dry, penetrative sex can range from uncomfortable to genuinely painful. Micro-tears in fragile tissue can cause burning and bleeding during or after intercourse. She may tense up involuntarily in anticipation of pain (vaginismus), which makes penetration even more difficult. Over time, if sex consistently hurts, her body develops an aversive response — desire drops because her brain has learned to associate sex with pain rather than pleasure. She may start avoiding intimacy altogether, not because she doesn't want closeness, but because she's learned that closeness leads to pain. This avoidance can be confusing and hurtful for you if you don't understand the cause. She might make excuses, seem distant, or tense when physical affection begins escalating. The solution isn't pushing through pain or accepting a sexless relationship. It's addressing the underlying cause. With treatment (discussed in the next entry), most women experience significant improvement. In the meantime, use generous amounts of high-quality lubricant every time, extend foreplay significantly, focus on non-penetrative forms of intimacy, and make her comfort the primary goal. The message she needs from you: 'Your pleasure and comfort matter more to me than any specific sex act.'

The good news is that GSM is highly treatable, and the most effective treatments are also among the safest. Local vaginal estrogen is the gold standard. Available as a cream (Estrace, Premarin), tablet (Vagifem), ring (Estring), or insert (Imvexxy), it delivers low-dose estrogen directly to vaginal and urinary tissue. Because it acts locally with minimal systemic absorption, it's considered safe even for women with contraindications to systemic HRT, including many breast cancer survivors. Benefits typically begin within 2–4 weeks and continue improving over months: tissue thickens, lubrication improves, pH normalizes, and urinary symptoms often resolve. Prasterone (Intrarosa) is a vaginal DHEA insert that converts to estrogen and testosterone locally. It improves vaginal health and can enhance sexual function. Ospemifene (Osphena) is an oral medication for women who prefer not to use vaginal products. For urinary symptoms specifically, pelvic floor physical therapy is highly effective for urgency, frequency, and incontinence. A specialized PT can assess pelvic floor function and provide targeted exercises and manual therapy. Over-the-counter vaginal moisturizers (like Replens or hyaluronic acid-based products), used several times per week independent of sexual activity, improve baseline comfort. Lubricants are essential during sexual activity but aren't sufficient alone for tissue health. The key message: GSM doesn't have to be part of her life. Treatment works, and the barrier is almost always awareness and willingness to seek help — not lack of effective options.

Very likely, yes. Recurrent urinary tract infections are one of the hallmark features of GSM, and the connection is direct. Before menopause, estrogen maintains a healthy vaginal microbiome dominated by Lactobacillus bacteria, which produce lactic acid and keep the vaginal pH acidic (3.5–4.5). This acidic environment suppresses the growth of pathogenic bacteria. After menopause, as estrogen drops, Lactobacillus populations decline, pH rises to 5.0–7.0, and harmful bacteria — particularly E. coli — can colonize the vaginal and urethral area more easily. Additionally, thinning urethral tissue and decreased blood flow make the urinary tract more vulnerable to infection. Up to 15% of postmenopausal women experience recurrent UTIs (3 or more per year), and many cycle through repeated courses of antibiotics without addressing the underlying cause: estrogen deficiency. Local vaginal estrogen is remarkably effective for preventing recurrent UTIs. Studies show it reduces UTI frequency by 36–75% by restoring the vaginal microbiome, lowering pH, and improving tissue health. This is one of the most evidence-backed indications for vaginal estrogen, and many urologists and urogynecologists now recommend it as first-line prevention. If she's suffering from recurrent UTIs and hasn't tried vaginal estrogen, it should be discussed with her healthcare provider as a priority.

This topic requires your most compassionate communication. Vaginal and urinary symptoms sit at the intersection of health, aging, sexuality, and femininity — all loaded topics. She may feel ashamed, broken, unfeminine, or worried about how you perceive her. Your approach sets the tone for whether she feels safe enough to be honest with you. Start by normalizing the conversation rather than targeting her specifically. Something like: 'I was reading about how common vaginal changes are after menopause. I want you to know that if that's something you're experiencing, we can figure it out together. There are apparently really good treatments.' This opens the door without putting her on the spot. If she's already mentioned symptoms, respond with curiosity and concern, not discomfort: 'Thank you for telling me that. What would be helpful? I want to make sure you're comfortable.' Avoid clinical language that sounds like you're diagnosing her. Never express that you find the situation unappealing. And recognize that urinary symptoms — urgency, leaking, frequent bathroom trips — can be embarrassing in a way that she may not readily discuss. If you notice she's going to the bathroom more frequently or seems anxious about access to restrooms, you can create ease without naming it: choosing restaurants with accessible bathrooms, suggesting breaks on road trips, keeping her comfort in mind during activities.