The labia minora and other parts of the vulva can change during the years leading up to menopause and beyond. Fenwa Milhouse, M.D., a board-certified urologist, urogynecologist, and women’s health specialist, believes symptoms affecting the vulva, vagina, and bladder are among the most overlooked aspects of this stage of life.

“Menopause is not just hot flashes and night sweats,” Dr. Milhouse told ThisIsMenopause.

Here’s what to know about why the vulva may change during menopause, common symptoms to watch for, and treatment options that may help.

What Is the Vulva?

The vulva is the external (outside) genital area. It includes the clitoris, urethral opening, labia minora (inner lips), labia majora (outer lips), vaginal opening, and perineum, the area of skin between the vaginal opening and anus.

People often use the word “vagina” for this area, but the vagina is the internal canal that connects the vulva to the cervix and uterus.

What Vulvar Changes Can Happen During Menopause?

Menopause can affect both the appearance and function of the vulva, but these changes are often overlooked or mistaken for other problems.

“Women often miss the vulvovaginal symptoms that occur during menopause,” Dr. Milhouse said. “They misattribute it to a yeast infection or a dermatologic issue.”

“Your vulva changes with age. And those changes can interfere with intimacy, change your bladder, and increase your risk of urinary tract infections.”

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— Dr. Fenwa Milhouse

Dr. Milhouse said some vulva changes can be felt, such as burning, pain, or itching, while others can be seen.

“If you lined up a bunch of vulvas and I couldn’t see the patient, I didn’t know anything about their age or anything, I could probably tell you which one is postmenopausal and which one is premenopausal,” Dr. Milhouse said. “They look different.”

Some changes are specific to the labia minora, clitoris, urethra, and surrounding structures.

Changes to the Labia Minora

As estrogen levels decline, the labia minora lose collagen and elasticity and may become thinner or smaller. They may also change in color or texture.

Some people experience irritation, tenderness, or itching around the labia. Less commonly, the labia minora can become irritated and partially stick together, a condition called labial adhesions. Your labia minora may also become more irritated or sensitive during sexual activity or masturbation.

Changes to the Clitoris

Like the labia minora, the clitoris is affected by estrogen levels, which help support healthy blood flow and tissue function. So declining hormone levels can affect it, too.

“We see changes in the clitoral hood and the clitoris,” Dr. Milhouse said. “Patients often say, ‘It feels like my clitoris has shrunk in size.’”

Dr. Milhouse explained that the clitoris has a hood that should peel back like a hoodie, but sometimes the hood sticks over the head of the clitoris and is harder to retract or can’t be peeled back at all. This can reduce sensitivity or make sexual stimulation feel different. Many people report that it is harder or takes longer for them to orgasm during and after perimenopause.

Changes to the Urethra

As estrogen levels decline, the tissues around the urethra may become thinner, making the urethral opening more noticeable.

“Before menopause, the urethral opening is often difficult to see,” Dr. Milhouse said. “After menopause, especially without estrogen treatment, it can become much more noticeable.”

Some people develop a small noncancerous red growth at the opening to their urethra, called a urethral caruncle. Urethral caruncles can bleed or cause discomfort, but symptoms often improve with vaginal estrogen treatment.

These estrogen-related changes in the urethra make it easier for women to get urinary tract infections in perimenopause and postmenopause. If you have two or more urinary tract infections in six months or three or more in one year, talk with your provider about treatment with vaginal estrogen therapy to reduce your risk of recurrent UTIs.

Genitourinary Syndrome of Menopause

Changes to the vulva are often accompanied by vaginal and urinary symptoms known as genitourinary syndrome of menopause (GSM), formerly called vaginal atrophy.

Common symptoms of GSM include:

• Vaginal dryness
• Vaginal burning or itching
• Changes in vaginal discharge
• Pain during sex
• Bleeding or spotting, especially during or after sex
• Frequent UTIs
• Painful or frequent urination
• Urinary incontinence

GSM is extremely common. It affects an estimated 50 percent to 90 percent of women in perimenopause and beyond, according to Dr. Milhouse.

“Never wait for it to get bad. Because the worse it gets, the harder it is to reverse.”

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— Dr. Fenwa Milhouse

Treatments for Vulva Changes in Perimenopause

Dr. Milhouse encouraged women to be proactive about seeking treatment for GSM and other vulva symptoms. “Never wait for it to get bad,” she said. “Because the worse it gets, the harder it is to reverse.”

Below are some treatment approaches to consider.

Vaginal Estrogen

Vaginal estrogen is an effective treatment for genitourinary symptoms of menopause. It can help improve moisture, elasticity, blood flow, and overall tissue health by restoring estrogen directly to the vagina and vulva.

It can also help reduce pain during sex, improve urinary symptoms, and lower the risk of recurrent UTIs.

When Dr. Milhouse discusses menopause with women over 40, she sometimes recommends using vaginal estrogen before symptoms occur.

“You don’t have to wait to get to menopause to start hormones,” Dr. Milhouse said.

Unlike systemic hormone therapy, which circulates throughout the body, vaginal estrogen acts mainly in the vaginal and vulvar tissues. It’s generally available as a vaginal estrogen cream, tablet, insert, or ring.

If you’re experiencing vulvar or vaginal dryness, burning, itching, painful sex, frequent UTIs, or urinary symptoms, ask your healthcare provider whether vaginal estrogen may be right for you. They can help you decide which form best fits your needs and preferences.

Lubricants

Personal lubricants can help reduce friction and make sexual activity more comfortable. They’re available over the counter in several forms, including water-based, silicone-based, and oil-based products.

Dr. Milhouse cautions that lubricants shouldn’t be the only approach to menopause-related dryness. While they can make sex more comfortable, they don’t address the hormonal changes that cause vulvar and vaginal tissues to become thinner and drier.

Moisturizers

Vaginal moisturizers can also help relieve dryness and discomfort. Unlike lubricants, which are used during sex to reduce friction, moisturizers can be used regularly to help keep tissues hydrated.

“Lubes are what you apply before the act,” Dr. Milhouse said. “Moisturizers are your day-to-day lotions.”

Pelvic Floor Physical Therapy

Some women develop pelvic floor tension or pain in response to ongoing vulvar discomfort. This can lead to painful sex or difficulty with penetration. Pelvic floor physical therapy can help address these problems, as well as issues like incontinence.

A pelvic floor physical therapist can help evaluate your pelvic floor muscles and teach you techniques to improve pelvic floor function and reduce pain and discomfort.

How To Be Proactive About Your Vulvar Health

Dr. Milhouse encourages people to be proactive and not wait until symptoms become severe before seeking help. Knowing what changes can occur can help you recognize symptoms early.

“Knowledge is power,” Dr. Milhouse said. She also recommends getting to know your body.

“One habit I recommend every woman over 40 start today is to take a mirror and look at their vulva weekly or monthly,” Dr. Milhouse said. “Put it into your regular self-care exam.”

During a self-exam, you can look for changes in the skin, color, texture, sensation, or appearance of the labia, clitoris, and other parts of the vulva.

Talk with your gynecologist, OB-GYN, or other women’s health provider if you notice persistent dryness, itching, burning, painful sex, changes in urination, recurrent UTIs, vulvar skin changes, or any other changes that concern you.