Estrogen is the queen of hormones. From our brains to our bones to our bottoms, estrogen keeps our systems regulated, lubricated, elastic, and running smoothly. Estrogen doesn’t just trigger sexual development in our breasts, uterus, vagina, and ovaries (although it does that, too), but it also regulates the production of cholesterol in our liver; it affects mood and body temperature from the brain; it protects again loss of bone density; and it keeps our sexual organs responsive and functional.
Estrogen is actually a category—a group composed of three chemically similar hormones. Estrone and estradiol are mostly produced in the ovaries, adrenal glands, and fatty tissue of all female mammals. Estriol is produced by the placenta during pregnancy. These estrogens circulate in the bloodstream and bind to receptors located throughout our bodies.
Not surprisingly, most of those estrogen receptors are located in the vulva, vagina, urethra, and the neck of the bladder, and that's why we talk about estrogen so much in this blog and at MiddlesexMD. It’s the critical hormone that keeps our sexual apparatus healthy and functional.
Before menopause, a healthy vagina has
- thick, moist “skin,” or epithelium
- tissues with many folds (rugations) that allow the vagina to expand and become roomier
- differentiated layers of cells—superficial and intermediate
- secretions from the vaginal walls and cervix that help maintain a slightly acidic pH balance
- an increase in blood flow and lubricating secretions during sexual arousal
- toned pelvic floor muscles that help to hold our internal organs in place
So, ladies, it’s easy to see that when our estrogen levels drop dramatically during menopause, virtually all of us will experience significant change to our vulvovaginal tissue. The umbrella term for that change is “vulvovaginal atrophy.” Here’s what happens to our genital area when we lose estrogen:
- the epithelium becomes pale, thin, and more likely to tear
- the vagina shortens and narrows
- vaginal walls lose rugations (those folds or pleats) and become smooth
- cells become less differentiated—there are more intermediate and fewer superficial cells
- the vagina becomes dry without secretions to maintain a good pH balance or to lubricate during sex
- the vulva shrinks and pubic hair thins
- the pelvic floor loses muscle tone, so organs relax and sometimes sag (prolapse)
It’s not a pretty list, but it’s our new, postmenopausal normal. Vaginal atrophy can bring more frequent vaginal and urinary tract infections as well as more painful sex. And since painful sex usually means less sex, both our relationship and our quality of life can suffer.
Fortunately, as we’ve discussed many times in this blog and at the MiddlesexMD website, there are simple and effective ways to ease the effect of estrogen loss. These include using moisturizers and lubricants or topical estrogen products, doing our kegels, and talking to our doctors about vulvovaginal changes.
Losing estrogen and its beneficial effects is inevitable as we grow older, but losing function, sexual or otherwise, isn’t. Sex—and life—can be just as enjoyable. They just take more maintenance now.
Dr. Barb DePree, M.D., has been a gynecologist and women’s health provider for almost 30 years and a menopause care specialist for the past ten.