TLDR. Shifting estrogen levels impact both the tissue and the microbiomes of the vulva, vagina, urethra and bladder, which can lead to vaginal dryness, itching, pain during intercourse, and urinary issues which can all have a significant impact on quality of life. You're not alone, nearly 50% of women experience one or some symptoms related to these systems, and concerning changes require treatment or intervention to alleviate pain or discomfort as they are likely to persist or worsen as women move into post menopause.
The vulva, vagina, urethra, and bladder all have estrogen and androgen receptors. As these hormone levels fluctuate in perimenopause, the tissues that depend on these hormones undergo a structural change. Symptoms associated with these changes include vaginal dryness, itching, pain during intercourse, and urinary issues. Urinary issues may include urgency, increased frequency, painful urination, and recurrent UTIs (American Urological Association).
As estrogen levels decline, the vaginal walls often thin and lubrication often declines which can both lead to an increased likelihood of painful sex (Tiwari et al, 2025). Lactobacillus are the predominant microbiota in the biome of the vagina before the overall decline in estrogen which begins in perimenopause. Once estrogen declines the pH increases (shifts from acidic to alkaline) and the number of lactobacillus decreases, disrupting the bacterial population balance . When the balance of the microbiome is out of balance, there is an increased opportunity for pathogenic organisms to take over potentially leading to an increased susceptibility to infections. (Mercier et al, 2023)
Women who suffer from urinary changes including symptoms in their urinary tract are 7x more likely to experience painful intercourse and are 4x more likely to have issues becoming sexually aroused. The two systems are linked, and treating urinary issues can have significant impacts on sexual health and quality of life. (Wasserman & Rubin, 2023)
These physiological symptoms can have psychological impacts impacting a woman’s libido and sense of well being (Moshfeghy et al, 2020). It is important to consider treatment options for both physiological and psychological impacts of these changes.
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Naming. All of the changes related to these systems (Reproductive & Urinary) were grouped together in 2014, to be called Genitourinary Syndrome of Menopause (GSM); Genitourinary refers to both the reproductive & urinary systems. This replaces prior terminology of atrophic vaginitis or vulvovaginal atrophy, which did not fully represent the scope of symptoms or organs affected, and indicated the conditions as a disease state, rather than a spectrum of symptoms related to normal hormone changes through the life cycle.
What next? Because the symptoms are linked to consistently lower levels of estradiol, this is a set of symptoms that can worsen as women move into later postmenopausal years. Unlike many symptoms of the perimenopause transition, they are unlikely to get better with time. Changes to these systems can also feel particularly uncomfortable given how closely they're tied not just to physical comfort but also to your sexual health and sense of wellbeing.
There are actions which can be taken to alleviate symptoms and Flourish Through this phase of life.
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