Happy vagina, happy life: the frank conversation with a gynae you need to hear

Gynaecologist and female hormone expert Dr Tania Adib, wants every woman to have a happy vagina. It’s her mission after years in the NHS running, among other things, a vulva clinic, and now working in private practice. As a woman in her 50s, she has been through many of the issues her patients come with. So many women, she says, are needlessly living with vaginal discomfort that we’re too embarrassed to seek help for, or that we don’t know can even be helped.

“Vaginal health has such a massive impact on how we perceive ourselves,” says Dr Adib. “It has a huge effect on our self-confidence, our femininity, on how we feel as a woman. It affects how we function day-to-day. I’ve seen how I can help women feel so much better, to function normally, to go back to work, back to the gym, back to having a normal sex life, and to be able to look after their children without constantly running to the bathroom, leaking. I really would like women to know that there is a solution for pretty much all the problems that they have related to vaginal health.”

Full disclosure, Dr Adib has been my gynae for several years; she has tweaked my HRT as I’ve gone from perimenopause to menopause as my symptoms have changed, armed me with information to take to my GP, done annual blood tests to check my hormone levels and performed yearly vaginal radiofrequency treatments to keep my menopausal leaks in check.

Her advice helps me to have a better day every day, and whenever I see her, it’s always an education. I learn so much about vaginal health –  but more than that, I feel really empowered by her matter-of-fact positivity. “I just get huge joy from being able to support women, make them feel better, get them back to getting their confidence back, and going out in the world and being able to be amazing women and contribute to society, to flourish into the wonderful women that they are,” she says.

Her advice is something every woman should know, so on my most recent visit, I pressed record on our conversation – and I think you’ll be gripped!

Why do we need to talk more about vaginal health?

Says Dr Adib, “It’s not well addressed; in fact, it’s often dismissed. Because it’s an organ we can’t see and it’s one that we are embarrassed about talking about, women just put up with symptoms. The vagina changes throughout life, with age, with events like pregnancy, childbirth, menopause and surgery.

“We need to feel more comfortable about talking about vaginal health and symptoms, and most importantly, tell women that there are solutions for pretty much everything. They don’t have to put up with dryness, itching, discomfort, recurrent UTIs, laxity, not having any sensation during intercourse, prolapse, or incontinence. There are always things that we can do.”

Hooray! Tell us, how does the vagina (and vulva) change as we age?

“Each decade it changes. But typically:

In your 20s: “As well as having high oestrogen, you have the highest testosterone levels in your 20s. There are both testosterone and oestrogen receptors in the vulva (meaning the cells need these hormones to function well). Testosterone supports both pelvic floor muscle maintenance and, alongside oestrogen, supports vaginal hydration. Oestrogen helps create collagen and elastin, so both your bladder and vagina/vulva are generally well supported. At this age, the whole area is well moisturised and hydrated and your pelvic muscles are really toned.

“If you are on the contraceptive Pill, however you may experience dryness. Vulvar pain (vulvodynia, see below) can happen at any age.”

In your 30s: “Testosterone starts to dip after the age of 30. That will affect how the vulva and vagina feel in terms of dryness and the pelvic floor muscles.

“You may start having babies at this point and so the pelvic floor may weaken from the weight of carrying the baby. The vagina may start to widen if you’ve had one or more vaginal births. You will start to experience vaginal laxity and maybe stress incontinence.”

In your 40s: “Vaginal dryness can start ten years before the menopause while women are still having periods, so from your early 40s, you’ll likely experience this as testosterone and oestrogen levels dip. That will affect both vaginal hydration and the pelvic floor muscle. Typically, by the age of 40, testosterone levels are 50 per cent lower than they were in your twenties.”

In your 50s and 60s: “At this stage, you’ll likely have very significant dryness, pelvic floor weakness, vaginal laxity and bladder issues. How you feel and the symptoms you experience depend on whether you are using hormones (HRT) or not.

“We talk about GSM, the Genitourinary Syndrome of Menopause. It’s actually a triad of symptoms: vaginal, urinary and sexual. It’s helpful to think of them all together, as in my experience, the sexual symptoms, especially, are often forgotten. Why? Because women are told just to have a glass of wine and think of England –  think that’s why there are so many divorces in women this age, because they get to the menopause, they’re not aware that vaginal dryness can be the reason they no longer find sex enjoyable.

In your 70s, 80s and 90s: “All women in their 70s and their 80s should be using vaginal oestrogen to support bladder health and help prevent UTIs (urinary tract infections), which become more frequent and more serious, at this stage. Following a recent study on older women in care homes who had UTIs, a long list of treatments was suggested, such as drinking more water and going to the toilet more often. But nowhere on the list was using vaginal oestrogen.

“Vaginal health is especially important as we age, for bladder health. A UTI can become a kidney infection, and then can become sepsis. And that costs millions a year for the NHS. A vaginal oestrogen pessary is cheap, widely available, and your GP can prescribe it. There’s one called Gina that you can buy over the counter from a pharmacy.”

How do you know if you have vaginal dryness – what does it feel like?

“You may feel burning or itching on a day-to-day basis. You may need to go to the toilet more often. It might hurt to wipe because the skin is so dry on the outside. It may hurt to walk because it’s rubbing on the vulva. Sex feels painful, like razors or sawdust. Dryness can also cause bladder symptoms (see below). I’ve seen all those.”

What can you do? Is vaginal oestrogen effective?

“Vaginal dryness, which can start ten years before menopause, happens due to decreasing levels not just of oestrogen, but also of testosterone. Replacing those hormones can bring back hydration.

“Topical oestrogen cream and pessaries are available on the NHS, but often oestrogen on its own doesn’t quite hit the mark. A lot of women who use it tell me that it still doesn’t fix the dryness, and that sex still hurts on entry. It’ll fix the upper vagina, because that has mainly oestrogen receptors. But in the lower vagina and the vulva are mainly testosterone receptors (meaning the cells rely on that hormone to function normally). I will often prescribe a custom mix of testosterone and oestrogen cream to use in the vagina and the vulva.

“Alternatively, there is a pessary called Intrarosa, which is DHEA, a hormone that converts into oestrogen and into testosterone in the cells in the vagina and the vulva. It’s available privately and in some parts of the UK on the NHS.”

Is vaginal dryness just a perimenopause issue, or can it happen earlier?

“No, a lot of women who are breastfeeding get dry vaginas, because they are not making oestrogen – that’s why women often don’t have a period until they stop breastfeeding. Some women who are on the Pill get dry vaginas as well, because the Pill is synthetic oestrogen that suppresses their natural oestrogen.

“In addition, this high dose of synthetic oestrogen raises SHBG (sex hormone binding globulin), which mops up all the testosterone in your body, meaning there’s no free testosterone to be used to support the vulva and the labia.

“Some women even develop vulvodynia (vulvar pain) because of low testosterone. I can help them by giving them the combination hormone cream.”

Vaginal laxity – why does it happen and what can you do?

“A lot of women suffer with laxity after childbirth – the vagina has been stretched so widely by the baby’s head, and the fibres never quite heal and come together. It’s often not taken seriously – women with laxity don’t experience any pressure or friction during sex because there’s no contact – the vagina just remains wide. For the men, it doesn’t feel as good either.

“Vaginal radiofrequency (such as Emfemme) works incredibly well for laxity (and urinary incontinence) because it gets the elastin fibres to re-engage and heal. It tightens and firms and strengthens the vaginal walls, improves blood flow and improves sensation.

“A lot of women in the United States have radiofrequency six weeks after giving birth, to help the vagina heal immediately. You can experience laxity without having a vaginal birth, but it’s rare.

Why has my bladder got worse in menopause?

“The urinary symptoms of menopause are mild stress incontinence and urge incontinence. You may have one or both.

“Stress incontinence is where you leak when you sneeze or cough. It’s a mechanical leak because the pelvic floor has been weakened, through the weight of the baby in pregnancy, causing the bladder to drop. The stretching of the vaginal walls in childbirth affects the bladder, too. Menopause and age can both be factors.

“Radiofrequency can help, because it strengthens the vaginal wall by generating more collagen and elastin, and it can lift the bladder. And I often use that in conjunction with the Emsella Pelvic Floor toning chair, which strengthens the pelvic floor. (Read more about treatments for urinary incontinence and leaks)

“PRP (platelet-rich plasma) injections underneath the urethra work well as they create a bulking effect around the urethra, helping it to close when you don’t want to wee. I have women who come for radiofrequency and PRP, once a year, to support bladder health as a maintenance.

“More affordable alternatives would be pelvic floor exercises, Pilates, specialist exercises from a physiotherapist, and there are plenty of Kegels apps to follow.

Urge incontinence – when you gotta go, you gotta go

“Urge incontinence is an irritated bladder – you need to go more often, you need to dash, and you might leak. While this is largely to do with age, menopause is also a factor as the drop in hormones causes dryness, which further irritates the bladder.

“Your GP can prescribe medication to calm the bladder. Radiofrequency can also be very effective for urge incontinence, because the heat can calm the bladder nerves down. I’ve seen really great results where women don’t need to go quite so often.

“Vaginal oestrogen can help too, as the bladder and the urethra have oestrogen receptors, meaning they don’t work as well without it.

Drinking fluids late at night is a health hazard

“If your bladder is already weak, you’re more likely to need the loo in the middle of the night, and so it’s important not to drink too much late at night. Needing to go to the loo in the middle of the night is a health hazard as we get older, because we’re more likely to trip and fall and maybe break a hip. Sorting out the bladder is a really important issue.

Testosterone supplementation can help your pelvic floor muscles

“It becomes harder to build muscle mass as we age, but that’s not confined to your biceps and glutes. Our muscles become weaker in general and that includes the pelvic floor muscles. This is where testosterone therapy for women comes in.

“I talk to all my patients about testosterone, because when we’re in our 80s and our 90s, we still want to be independent, to be able to get up from sitting unaided, carry our own suitcase and continue to be strong, independent women. We need to stay active, to be exercising and potentially taking hormones to support that.

“Creatine is wonderful for muscle strength and also for cognition. I use Thorne Creatine, £30.99. I love collagen supplements too to support all the tissues. I use Skinade Collagen Drink, £82 as that’s the one most plastic surgeons use.”

A painful vulva – vulvodynia – can happen at any age

“Vulvodynia is a general condition that means vulvar pain, and there are many different causes. Sometimes we don’t know what the reason is, but it can be triggered by UTIs, by vaginal infections, by being on the oral contraceptive Pill, by stress and any kind of condition on the vulva.

“It occurs when the vestibule (a gland with multiple nerve endings at the opening to the vulva) is triggered and becomes hypersensitive. It is perceived as pain, usually intense burning.

“Some women have it all the time, others only have it on touch. It can be incredibly debilitating, because it has a massive effect on your mood and how you function. It can make sitting painful, it hurts to ride a bike, you often can’t use tampons, and many women with vulvodynia can’t have sex.

“It’s often poorly diagnosed; women are dismissed or told they have vaginismus (an overactive pelvic floor, which tightens, meaning nothing can get into the vagina).

“Women with vulvar pain often do get secondary clenching, because they’re tense, anticipating pain all the time. They’re often told just to put some local anaesthetic cream on or have a glass of wine!

“It’s a tricky condition to treat. There are lots of oral medications, such as amitriptyline, gabapentin, and pregabalin, which are pretty hardcore painkillers and notoriously associated with significant side effects such as drowsiness.

“I can prescribe custom-made pharmacy topical creams that don’t have the side-effects of oral medications – such as a topical gabapentin and amitriptyline. I might add the muscle relaxant baclofen, too.

Vulvodynia can go away, but it doesn’t always. So it’s often a question of managing it.

Any last words?

As women, we don’t prioritise our own health. We’re always prioritising the children, prioritising the husband, prioritising work, and then finally, we think about ourselves. We – and especially our vaginas – always come last.

Your vagina and vulva really do affect how you feel about yourself deep inside.

If you’re over 50, the only time a medical professional is likely to ask about your vagina is every five years at your smear test.

It’s hugely valuable to have a vagina MOT once a year; we don’t just have to go when there’s something wrong. Because a happy vagina is a happy life.

Book a consultation with Dr Tania Adib