Vaginal dryness and bladder changes in perimenopause

Why the vagina and bladder change together

The vagina, the vulva, the urethra and the base of the bladder all depend on oestrogen to keep their lining thick, moist and stretchy. When oestrogen starts to fall, they change at the same time, which is why dryness and bladder trouble so often turn up as a pair. The NHS perimenopause symptom list includes vaginal dryness, pain or discomfort during sex, recurrent urinary tract infections and incontinence.

Doctors now group these under one name, genitourinary syndrome of menopause, or GSM. A clinical review by two gynaecologists explains that the term was agreed in 2014 by the North American Menopause Society and the International Society for the Study of Women's Sexual Health. It replaced older names you may still see on a letter, such as vaginal atrophy and atrophic vaginitis.

The same review gives a sense of timing. One study it cites found GSM in 4% of women during perimenopause, 25% a year after menopause and 47% three years after. So it usually builds slowly and gets more common later, and some women notice it years before their last period. It also tends not to settle by itself, which is a good reason to mention it rather than wait.

Signs of vaginal dryness

The word "dryness" undersells it. The NHS vaginal dryness page lists these signs:

• soreness or itching in and around the vagina
• pain or discomfort, including during sex
• unusual discharge, spotting or bleeding
• needing to pee more often than usual
• urinary tract infections that keep coming back

The clinical review adds burning and irritation, and notes that discomfort can show up away from sex too: during exercise, in tight clothes, or after sitting for a long time. Many women only describe the part that bothers them most, so a GP may never hear about the rest unless you list it.

Needing to pee more and other urinary symptoms

Bladder changes in perimenopause take a few forms. You may need to go more often, feel a sudden urge that is hard to hold, get up in the night, or leak. The NHS incontinence page separates leaking into two common kinds: stress incontinence, when pee escapes as you cough, laugh or lift, and urge incontinence, when it leaks with or just after a sudden need to go. Some people have both.

The NHS is direct that incontinence of any type is worth a GP appointment and nothing to be embarrassed about. It also says that although it gets more common with age, it is not an inevitable part of getting older. A GP will usually ask about your symptoms, may do a pelvic examination, and may ask you to keep a diary of what you drink and how often you pee.

UTIs in perimenopause

Lower oestrogen makes infections easier to catch. The review explains that oestrogen keeps the vagina acidic, which protects it, and that as levels fall the vagina becomes less acidic and more open to bacteria from the bowel and skin. The NHS UTI page lists having been through the menopause as a risk factor in its own right.

The hard part is that a UTI and GSM can feel alike, because both bring frequency and urgency. These signs on the NHS list point more towards an infection:

• pain or burning when you pee
• pee that looks cloudy
• pain low in the tummy, or in your back just under the ribs
• a high temperature, or feeling hot and shivery
• feeling tired or weak

In the UK, the NHS says women aged 16 to 64 who are not pregnant can start with a pharmacist for a suspected UTI. If the "UTI" symptoms come back again and again and urine tests keep coming back clear, tell the GP that. It can mean the symptoms are coming from GSM, and the NHS also describes long-term infections that standard urine tests can miss.

Pain during sex in perimenopause

Pain with sex is one of the most common symptoms in the group and one of the least reported. The review describes it as pain on entry or deeper pain, sometimes with small tears or light bleeding afterwards. Pain that has gone on for a while can also make the muscles around the vagina tighten in anticipation, which adds a second problem to the first.

Bleeding after sex is its own item on the NHS list of reasons to see a GP, whatever you think the cause is. Our page on spotting between periods in perimenopause covers the other causes a doctor will want to rule out.

Look-alikes worth ruling out

Not every vaginal or bladder symptom in your 40s comes from oestrogen. The NHS pages name several other causes:

• Thrush brings itching and soreness, stinging during sex or when you pee, and usually a thick white discharge. The NHS thrush page says to see a GP the first time you have it, or if it comes back more than 4 times in 12 months.
• A urinary tract infection brings burning when you pee and often cloudy or smelly urine, and can come with a temperature.
• Medicines are on the NHS list of causes, which names hormonal contraception and antidepressants, and cancer treatments such as chemotherapy and hormone therapy.
• Irritants such as perfumed soaps, washes and douches can cause dryness and soreness on their own.
• Other conditions, including diabetes and Sjögren's syndrome, are linked to it too, and the NHS lists a hysterectomy, especially with the ovaries removed, as another cause.
• Sexually transmitted infections are still possible at any age, and the review notes that a less acidic vagina is more open to them.

If you are on hormonal contraception, it can also hide the cycle changes that would otherwise point to perimenopause. The page on hormonal contraception in perimenopause explains how.

When to see a doctor

Blood in your pee: an urgent appointment

The NHS blood in urine page says to ask for an urgent GP appointment or contact NHS 111 if you have blood in your pee, or think you might, even a small amount. It may look bright pink, red or dark brown. It is not usually serious, but the NHS asks for it to be checked because it can be a sign of cancer, which is easier to treat when found early.

In perimenopause it is easy to put pink in the toilet down to a period. The NHS lists a period, bleeding from the vagina between periods, beetroot and some medicines as things that can look like blood in pee. Unless you are sure which it is, get it checked, and in the US call your doctor's office.

Other urgent signs

The NHS UTI page asks for an urgent GP appointment or NHS 111 if you have UTI symptoms with any of these:

• a very high or low temperature, or shivering
• pain low in the tummy or in your back, just under the ribs
• symptoms that get worse quickly, or are no better within 48 hours of starting treatment
• diabetes, pregnancy or a weakened immune system
• repeated infections: 2 within 6 months, or 3 within 12 months

Back pain and fever can mean a kidney infection, which can lead to sepsis. If you become confused, drowsy or find it hard to speak, the NHS says to call 999 or go to A&E, and not to drive yourself.

A routine GP appointment

For dryness, the NHS suggests a routine appointment if it has lasted a few weeks and what you have tried yourself is not helping, if it is affecting your daily life, or if you have unusual discharge. Its page lists the things you can try at home first. Book sooner if you bleed after intercourse or between periods, and treat any bleeding after menopause as a reason to go. The page on bleeding after menopause explains why.

What to tell your GP

The review found many women never connect these symptoms with menopause. In one survey of over 3,500 postmenopausal women it cites, only 4% linked their vaginal symptoms to falling oestrogen, and it says many women wait to be asked. Coming in with the details saves you from having to find the words on the spot. I would bring:

• which symptoms you have: dryness, itching, burning, pain during sex, needing to pee more, urgency, leaking
• when each one started and whether it is mild, moderate or severe
• how many UTIs you have had in the last year, and whether urine tests confirmed them
• any blood in your pee, bleeding after sex or bleeding between periods
• your period dates for the last few months
• every medicine you take, including contraception and antidepressants
• a few days of what you drink and how often you pee, if leaking or frequency is the main problem

The printable symptom diary and appointment checklist has a section for bladder and vaginal symptoms and adds a question about them to your list.

My take

I would put vaginal and bladder symptoms on the agenda at the same appointment as everything else, said in plain words, because they are part of the same change and the review is clear that doctors often do not ask. The one I would never sit on is blood in the pee: book it urgently even if you suspect it is your period. I would also count the UTIs. Three "infections" a year that each needed a pharmacy visit is a pattern a GP should hear about, and a clear urine test in the middle of it is useful information too.

Related reading

These changes sit alongside the rest of the list in perimenopause symptoms and how to track them, and the perimenopause symptom checklist helps you see whether the picture fits. The symptoms topic collects every symptom page on the site.