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Menopause occurs on average at age 51 in the United States. With a life expectancy of 78 years, the average woman is postmenopausal for one-third of her life. Hot flashes are the most common symptoms around the time of menopause. Other common postmenopausal signs and symptoms include vaginal dryness, thinning, and bleeding. Menopausal symptoms last longer than 5 years in 25% of women and continue throughout life in a small percentage of women.

Despite the controversy about the risks and benefits of estrogen replacement therapy, many women and their healthcare providers choose to treat low levels of estrogen in menopause. Estrogen replacement therapy is approved by the US Food and Drug Administration to treat menopausal symptoms, including vaginal dryness, and to prevent osteoporosis. However, estrogen replacement is becoming less popular because of recent research findings that suggest increased risks of breast cancer, uterine cancer, stroke, and deep-vein thrombosis in women.

Hot flashes and similar symptoms usually disappear within the first cycle of estrogen treatment. Treatment is started at a low dose that is increased gradually until symptoms improve. Progestin (progesterone) therapy is considered when estrogen cannot be given for any reason. Other drugs (eg, clonidine, methyldopa, or belladonna alkaloids) can also relieve some symptoms.

Disorders of the vulva, labia, and surrounding skin become more common as women age. The skin of the vulva is less elastic or flexible, and the underlying fat and connective tissues can break down. These changes can lead to a variety of disorders and symptoms. Common disorders include irritation, inflammation, and infection. Tumors of the vulva are fairly rare but do develop in some postmenopausal women.

Inflammation and irritation can develop from allergic reactions, as well as from fungal, yeast, or bacterial infections. The skin in this area perspires more than skin elsewhere, and the added moisture increases the potential for irritation and infection. Hygienic products used for urinary or fecal incontinence can also irritate the area, as can urine or feces. Infection or irritation causes uncomfortable redness, itching, swelling, or pain around the vulva. Burning or pain should be medically evaluated, because it is rarely due only to age and estrogen deficiency.

The skin around the external genitalia can become thickened from hormonal changes and chronic irritation. The labia and surrounding skin may darken or lighten, depending on the specific problem and factors such as scratching and hygiene. Such changes rarely lead to cancer but can cause itching, vaginal soreness, and pain during sex. Thickened areas can also cause the labia or vaginal opening to shrink.

Tumors of the vulva may show up as multiple thickened or pigmented areas. Most of the time, there are no symptoms, but itching sometimes develops. Most tumors of the vulva are not malignant, but this is always a possibility. Vulvar cancer becomes more common with age, with half of all cases developing in women older than 70 years.

Abnormalities in the external genitalia are frequently linked to other medical problems (eg, metabolic disorders). Most conditions generally improve greatly with treatment.

Physical examination of the affected area is important for diagnosis. Your healthcare provider may apply a small amount of a weak acetic acid solution before examining the area with a special instrument. The acetic acid causes suspicious areas to turn white and can improve the chance of finding abnormalities. If there are suspicious or affected areas of the vulva, a biopsy should be taken of all to rule out cancer. In this procedure, local anesthesia is used to numb the area, and a very small amount of tissue is removed for examination under a microscope.

Treatment is directed at the underlying problem. Bacterial infections can be treated with antibiotics and gentle cleansing of the area. Fungal or yeast infections, which are common in diabetic and obese women or after a course of antibiotics, can be treated with antifungal agents (oral, intravaginal, or applied to the surface). Corticosteroids can be applied to the affected area to relieve inflammation and itching. They are particularly useful for treating thickened areas. Thickened areas that extend into the vagina may improve with use of estrogen cream. Wearing cotton (breathable) underwear and avoiding irritant soaps are also helpful. Applying emollient lotions that include lanolin helps sometimes, but petroleum jelly should be avoided.

Tumors of the vulva usually require surgery. Benign lumps can be removed individually, but malignant tumors may require more extensive surgery that removes the entire vulva and associated lymph nodes. Follow-up radiation may be needed.

The lining of the vagina commonly thins, pales, and becomes less elastic or flexible in postmenopausal women. Estrogen deficiency after menopause causes the lining of both the vagina and urethra (the tube that leads from the bladder outside the body) to weaken. Nearly all postmenopausal women have this problem, although the degree of symptoms varies. Common symptoms include vaginal dryness, inflammation, discharge, burning, bleeding, and pain during sex.

These postmenopausal changes greatly increase the overall chances of infection and irritation, and older women have more problems with vaginal irritation and infection than younger women. The types of bacteria and fungi that cause vaginal inflammation, however, are quite similar in older and younger women.

• Vulva and vagina
  • inflammation
  • ulceration
  • thinning (atrophy)
  • cancer
• Cervix
  • irritation or infection
  • cancer
  • polyps
• Uterus
  • thickening of uterine lining
  • thinning of uterine lining
  • swelling of glands in uterine lining
  • polyps or tumors (benign or malignant)
• Urinary tract
  • irritation or infection
  • tumors (benign or malignant)
  • stones
• Hormone replacement or problems
• Bleeding disorders (eg, blood thinners)

Vaginal thinning from lack of estrogen after menopause is a common cause of bleeding. Other common causes are urinary problems and hormone replacement therapy. Women on combined estrogen-progesterone replacement who continue to have bleeding after 12 months should be evaluated.

The chance of cancer being the cause of bleeding increases with age. About 20% of older women who have vaginal bleeding after menopause have cancer. You should see your healthcare provider for a full evaluation of any episodes of bleeding after menopause.

A complete physical examination is necessary, as well as diagnostic tests directed at possible underlying problems. A biopsy of the uterus, Pap smear, ultrasound, and possibly other tests may be needed to find the source of the problem. Any areas that appear abnormal are usually biopsied by removing a very small piece of tissue. Sometimes, a progesterone challenge test is done if no other cause for the bleeding has been found. In this test, progesterone is given for about 2 weeks. If bleeding occurs when progesterone is stopped, there is a problem in the lining of the uterus, and further evaluation is needed.

A Pap smear is a screening test for cervical cancer. A few cells are scraped from the cervix and examined under the microscope with a special stain. There is no upper age limit for this test, because the chance of developing cancer of the cervix increases with age. In fact, most cases of cervical cancer are in women older than 50 years, and women should continue to have regular Pap smears after menopause. There is no consensus regarding at which age women should stop having Pap smears. You should discuss your individual risks with your healthcare provider to decide this.

Estrogen treatment usually resolves the symptoms seen with vaginal thinning. Applying estrogen cream every day is effective, but it can be absorbed and cause side effects elsewhere in the body (eg, the uterus). For this reason, applying smaller amounts only once or twice a week is often recommended. This usually relieves symptoms with little (if any) absorption or side effects. Estrogen is also available as vaginal tablets or as a time-released ring (good for 3 months) that is placed in the vagina.

Increased sexual activity can also greatly improve vaginal thinning. Estrogen cream is an excellent lubricant for use during sex or for pessary insertion.

Vaginal bleeding that is caused by uterine problems can be treated with estrogen replacement therapy or surgery (eg, hysterectomy). The lining of the uterus can also be treated by techniques using heat or cold. This may be helpful for women whose bleeding is being caused by a condition other than cancer.

The pelvic structures are supported by a combination of muscles and ligaments. Injury during childbirth, obesity, vaginal thinning after menopause, and strenuous activities that increase pressure in the abdomen (eg, heavy lifting, chronic coughing, and constipation) cause this supporting structure to weaken over time. This loss of support can lead to sagging and prolapse of the uterus. In a prolapse, internal organs (eg, the cervix or uterus) can actually push their way outside the body through the vaginal opening. Common symptoms of prolapse include a full feeling in the pelvis, lower back pain, urinary or fecal incontinence, or difficulty with emptying the rectum.

Other organs that run alongside the genital tract, such as the urethra, bladder, and rectum, can also become prolapsed against the vaginal opening. When the bladder is involved, urinary tract infections (due to incomplete emptying) that keep coming back or urinary incontinence can result. When the rectum bulges up through the vaginal opening, difficult bowel movements or fecal incontinence can result.

Prolapse can be diagnosed during a thorough pelvic examination. Your healthcare provider will probably want to evaluate this condition both while you are standing and while you are lying down with your feet in the stirrups. During the examination, you will be asked to bear down or cough, to increase pressure in the abdomen and expose the prolapse.

A mild prolapse can be manually replaced and treated with a program of special exercises to increase muscle tone and support in the pelvic area. Estrogens may also be helpful in tightening the tissues in this area. Surgery is usually necessary for more severe prolapse. If the uterus has prolapsed, it is usually removed (ie, hysterectomy). Other surgical repairs may be necessary to tighten the pelvic area if the bladder and rectum have also prolapsed.

If prolapse keeps coming back despite routine surgery or other means (eg, pessaries), the walls of the vagina can be stitched together to close the vaginal canal. This procedure can be done under local anesthesia as an outpatient procedure. This surgery is of course appropriate only for older women who are not, and will not be, sexually active.

Physical activities are often limited for 6-12 weeks after prolapse surgery. Doing pelvic-floor exercises and considering the use of estrogen cream may be helpful during this time. The use of estrogen should be discussed with your healthcare provider. Prolapse surgery can greatly increase quality of life, because a large prolapse can seriously limit participation in physical and social activities.

A vaginal pessary is a device placed into the vagina to help support the uterus. Pessaries are commonly used to help delay or avoid surgery. For example, pessaries can provide comfort and restore bladder function when poor health makes surgery undesirable.

The choice of pessary depends on the degree of prolapse and tissue relaxation, whether there is incontinence, and ease of care. Pessaries are made from rubber, plastic, or silicone. A variety of shapes and sizes are available, including doughnuts, rings, cubes, inflatable balls, and foldable models. Women with prolapse and no incontinence require pessaries that only take up space. Women with stress incontinence (see Urinary Incontinence) benefit from a foldable type, which supports the bladder. Ring pessaries are easier to insert and remove and are preferred by many older women.

Pessaries are usually selected by trial and error. The best pessary fits snugly, but comfortably, and allows urinating and defecating without difficulty. Your healthcare provider will want to see you from time to time after you start using a pessary to make sure that you are not having problems. If the pessary becomes uncomfortable, a different size or type should be tried.

Pessaries need routine cleaning and follow-up. Older women who are able should remove the pessary twice a week, wash it with soap and water, reinsert it using a water-soluble lubricant, and consider using vaginal estrogen cream twice a week. The use of estrogen should be discussed with your healthcare provider. Women who are unable to perform this self-care can be checked periodically at their healthcare provider's office or by a visiting nurse. All women who use a pessary should have a pelvic examination once or twice a year. Between examinations, you should report any unusual discharge, bleeding, discomfort, or changes in bladder or bowel function.