Pelvic floor dysfunction during menopause has raised to a level that it became a common problem for women to face during the menopause. This will affect the pelvic muscles, which support the bladder, uterus, and bowel.symptoms like urinary incontinence, pelvic organ prolapse, and sexual discomfort are the common indication of weakening of pelvic tissue due to the decrease in levels of estrogen.
Pelvic floor changes and uterine prolapse symptoms
As menopause sets in some women may feel
- a sense of ballooning or pressure or bulging in the vagina.
- Sometimes they can even feel the cervix protruding outside the vagina if they strain at urine or stools.
- Others may get a low backache the longer they stand and a general discomfort and dragging sensation in the lower abdomen.
- Some women may notice a bulge in the vagina that needs replacing with fingers to allow them to pass stools or urine.
- Sometimes prolapse can get in the way of intercourse and make sex uncomfortable or painful.
- Rarely with advanced prolapse the protruding part can get ulcerated and bleed on touch or when rubbed by underwear.
All these are symptoms of uterovaginal prolapse or prolapse in common terms.
Causes of uterovaginal prolapse
We already discussed how the pelvic floor muscles, ligaments and genital structures have estrogen receptors. As estrogen levels decline throughout the body, collagen and elastin production decreases and existing tissues do not get repaired the same way as before menopause. This results in reduced tone and strength in the pelvic floor allowing the process of prolapse to take place.
Usually, pelvic organs can start to get displaced or ‘fall out’ because of damage to the ligaments and muscles that support the pelvic organs. This damage can happen during the following:
- pregnancy and childbirth
- menopause with decreasing collagen and elastin
- persistent coughing or chronic constipation
- heavy lifting or prolonged standing with straining
- surgery that damages pelvic nerves or ligaments and muscles
- a tumor or mass in the abdomen or even fluid (ascites) can precipitate a prolapse
About half of post-menopausal women have a bulge in the front wall of the vagina, a quarter of the back wall and about 20% with the top of the vagina or cervix. If prolapse of the top of the vagina happens after a hysterectomy it is called a vault prolapse.
Treatment of Uterovaginal prolapse
Treatment of prolapse depends on the severity and type of prolapse and the effect it has on quality of life.
Non-surgical treatment of prolapse
This includes pelvic floor exercise and physiotherapy, vaginal pessaries and vaginal estrogen treatment.
Surgical treatment of prolapse
The type of surgery offered depends on the prolapse itself, age of the patient, previous surgery, associated bowel or bladder problems.
Reconstructive surgery aims to repair and replace the prolapse to its original position so that organs like bowel and bladder work as normally as possible. This may sometimes mean removing the uterus and cervix to allow a proper repair to be performed. Sometimes such repair may need a material like a mesh (synthetic or patient’s own tissue) to be used to support the prolapsed vagina. Surgery can be done vaginally, abdominally or endoscopically.
Vaginal closure surgery is done in very infirm or elderly patients who cannot tolerate anesthesia or a major operation and are not sexually active. This usually involves pushing the prolapse back inside and closing the opening of the vagina.
Vulval skin changes in menopause
The skin of the vulva undergoes several changes in menopause. Decreasing estrogen levels means it becomes drier and less flexible. Vulval changes can be because of estrogen decline or because general skin changes in the body also affect the skin of the vulva.
Some common vulval problems are:
Vulvodynia
Vulval pain can cause physical, emotional and sexual problems
This is a condition where there is pain over the vulva. It can be throbbing, burning, stabbing or a sharp cutting pain.
The pain can be constant or come in waves and episodes.
The triggers could be a Herpes simplex infection, other sexually transmitted infections, trapped nerves following surgery or most commonly unknown reasons.
The decreasing estrogen levels in menopause can also trigger attacks of vulval pain and the frequency of attacks can increase during menopause.
Treatment is of the cause and associated psychological effects of chronic pain. Women often need counseling and support for partners is also encouraged.
Lichen sclerosus
Lichen sclerosus is a chronic skin inflammation that shows up as white scarred plaques. These can be painful and cause intense itching. Scratching can damage the skin further and get secondarily infected with bacteria. No one really knows the cause of this condition. The vulva can become scarred and papery and is easily damaged. Sex can become very painful and it is often accompanied with bladder problems. Rarely there is a risk of cancer in the skin affected by Lichen sclerosus.
It is important to never self-treat vulval skin conditions. Most over the counter preparations contain steroids and this can alter the appearance of the skin should a biopsy be needed.
Vulvoscopy is an examination of the skin of the vulva under a microscope. A mild solution of acetic acid and toluidine blue is used to study the cells under a microscope similar to a colposcope that is used to study the cervix.
Most gynecologists will do a small biopsy of the skin of the vulva to confirm the diagnosis and rule out cancer before prescribing local steroid creams to prevent the disease from progressing.
Lichen planus
This is a condition that affects the skin of the body particularly the mucous membranes. It can affect the vulva and vagina too and appears as purplish, itchy bumps on the vulva and white patches on the vagina.
This usually goes away on its own and may be triggered by stress and anxiety. Treatment is with topical creams after a vulvoscopy or biopsy.
Candida and other fungal infections
Fungal infections are common in the genital area because it is moist and warm. The pH of the vulva changes as a woman goes through menopause. The normal pH is acidic (between 3.5 – 4.5). When the pH changes and the skin becomes thinner and less moist, it becomes vulnerable to infections.
At the menopause women are also likely to suffer with diabetes mellitus that makes getting fungal infections much more likely. Treatment is with local creams or powders and oral antifungal tablets. Because of the nature of fungal infections, treatment can be prolonged.
Folliculitis
We have already discussed how the pH of the vulva changes as estrogen levels decline. The hair follicles on the pubic area also become dryer and the glands that normally lubricate the hair shaft also become dry. They can get infected easily with bacteria from the bowel and result in inflammation called folliculitis.
Shaving or hair removal can aggravate this problem.
It is best to just trim the hair with a hair trimmer rather than shave. If the hair poses a big problem it is probably better to opt for laser hair removal rather than shaving or hair removal creams or waxing.
Other skin conditions affecting the vulva
Other skin conditions can affect the vulva as well. E.g. psoriasis, dry skin conditions, bacterial skin infections, warts, herpes, sexually transmitted infections and their skin manifestations. The list is quite extensive.
It is very important to see your doctor for the correct diagnosis and to not self-treat.
Cosmetic procedures
Many women suffer with low self esteem due to changes in the appearance of the vulva as they go through menopause.
Various treatments that are included in vulval cosmetic surgery include laser vulval skin lightening, labiaplasty, clitoroplasty, labial fat infusion and mons pubis remodeling.
Vulval hygiene and skin care
The skin of the vulva is delicate and becomes fragile with lack of estrogen and ageing. The following skin care tips will be useful in keeping your vulva healthy.
- Wash the vulva with tepid water – avoid hot water as it dries out the skin too much.
- When you wash yourself make sure you wash from front to back. This is to avoid contamination with bowel bacteria. As you go through menopause this contamination is much more likely to cause persistent infection in the vagina and bladder.
- Avoid using body washes or soaps on the vulva – they are alkaline whereas the pH of the normal vulva is acidic. Use a wash that is specifically designed to be used on the vulva and is pH balanced for that purpose.
- Avoid using deodorants or perfumes on the vulva. If you think the area is smelly or the smell has changed get a check up from your doctor to rule out infections or other causes of a smelly discharge.
- Prefer to use cotton underwear and clothes that are light and airy. Avoid using tight or synthetic clothes that encourage sweating. At night you may wish to go without underwear.
- You can use homemade moisturizers or lubricants made with olive oil, coconut oil and aloe vera to soften and moisturize the vulval skin. If you do not get relief see your doctor.
- Avoid buying medicine or creams over the counter to treat your vulval dryness and itching. Using these can change the appearance of the skin if a biopsy is required and it can be harder to reach a diagnosis.
Conclusion
vulvodynia, lichen sclerosus, lichen planus, fungal infections, and folliculitis, these are the conditions women face due to the changes affecting the vulva during the menopause. Trying to reach out to a professional for the proper diagnosis and treatment will reduce the after effects. Discomfort caused by that can be reduced slightly by Maintaining vulval hygiene, using pH-balanced products, and embracing proper skin care practices. Overall understanding the changes will let you to have a chance of well-being.
Do write to me at masterthemenopause@gmail.com about what you liked in this article and whether it helped you address some of your concerns.