Uncover the three layers of the vaginal wall2,3

Trophic vaginal wall enables healthy sexual responses4–6

Vaginal wall physiology and function before menopause

  • The vaginal epithelium is moist with a well-lubricated, rugated surface7,8
  • Thickening of the vaginal epithelium allows the vaginal surface to expand and increase in length during sexual arousal5
  • The epithelium sheds, which offers protection against unhealthy organisms5
  • Vaginal pH is around 3.8 to 4.2, reflecting the production of lactic acid by lactobacillus organisms5
  • Superficial cells predominate8
  • The lamina propria contains blood vessels that become engorged with blood during sexual arousal, leading to lubrication4,6
  • The smooth muscle of the muscularis enables the vagina to dilate and lengthen during intercourse; relaxation of that muscle leads to arousal4

Decreased levels of estrogens and androgens lead to changes in all three layers of the vagina9,10

Vaginal wall pathophysiology and function after menopause

  • Vaginal epithelium loses its rugae and becomes thin11
  • The vagina narrows and shortens, reducing its elasticity and ability to expand or stretch11
  • Vessels and lymphatic structures are eroded and changes in the number of superficial and parabasal cells contribute to vaginal dryness during sexual arousal5,12

– Decreased vaginal lubrication may increase the risk for microtears during intercourse3

  • Vaginal pH typically increases to more than 5.0; increases in vaginal pH lead to greater susceptibility to infection8,11,12
  • The clitoral glans loses its protective covering, making it more prone to irritation from contact5
  • There’s a significant decrease in the vascularity of the lamina propria reducing its premenopausal function of becoming engorged with blood during sexual arousal, which led to lubrication4,13
  • Smooth muscle atrophy occurs in the muscularis layer, and after ovariectomy, as observed in a mammalian study, a significant decrease in the thickness of the muscularis was demonstrated2,4,13

The risk of dyspareunia, trauma, and infection increases due to vulvar and vaginal atrophy (VVA).8,12

VVA impacts most postmenopausal women10,14

50% of women 50 to 60 years of age

72% of women
70 years and older

While the prevalence of VVA is high, there’s low awareness and poor understanding of its associated symptoms12


1. Nappi RE, Kingsberg S, Maamari R, Simon J. The CLOSER (CLarifying Vaginal Atrophy’s Impact On Sex and Relationships) survey: implications of vaginal discomfort in postmenopausal women and in male partners. J Sex Med. 2013;10(9):2232-2241. 2. Berger L, El-Alfy M, Martel C, Labrie F. Effects of dehydroepiandrosterone, Premarin and Acolbifene on histomorphology and sex steroid receptors in the rat vagina. J Steroid Biochem Mol Biol. 2005;96(2):201-215. 3. Goldstein I, Dicks B, Kim NN, Hartzell R. Multidisciplinary overview of vaginal atrophy and associated genitourinary symptoms in postmenopausal women. Sex Med. 2013;1(2):44-53. 4. Goldstein I. Female sexual function and dysfunction. In: Raz S, Rodriguez L, eds. Female Urology. 3rd ed. Philaelphia, PA: Saundes Elsevier;2008:505-524. 5. Goldstein I. Recognizing and treating urogenital atrophy in postmenopausal women. J Womens Health (Larchmt). 2010;19(3):425-432. 6. Jannini EA, d’Amanti G, Lenzi A. Histology and immunohistochemical studies of female genital tissue. In: Goldstein I, Meston CM, Davis S, Traish A, eds. Women’s Sexual Function and Dysfunction: Study, Diagnosis, and Treatment. Boca Raton, FL: CRC Press;2005:125-133. 7. Mac Bride MB, Rhodes DJ, Shuster LT. Vulvovaginal atrophy. Mayo Clin Proc. 2010;85(1):87-94. 8. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause. 2013;20(9):888-902. 9. Labrie F, Martel C, Pelletier G. Is vulvovaginal atrophy due to a lack of both estrogens and androgens? Menopause. 2017;24(4):452-461. 10. Labrie F. DHEA after menopause: sole source of sex steroids and potential sex steroid deficiency treatment. Menopause Manag. 2010;19:14-24. 11. Castelo-Branco C, Cancelo MJ, Villero J, Nohales F, Juliá MD. Management of post-menopausal vaginal atrophy and atrophic vaginitis. Maturitas. 2005;52(Suppl 1):S46-S52. 12. Wysocki S, Kingsberg S, Krychman M. Management of vaginal atrophy: implications from the REVIVE Survey. Clin Med Insights Reprod Health. 2014;8:23-30. 13. Semmelink HJ, de Wilde PC, van Houwelingen JC, Vooijs GP. Histomorphometric study of the lower urogenital tract in pre- and post-menopausal women. Cytometry. 1990;11(6):700-707. 14. Sturdee DW, Panay N; International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13(6):509-522. 15. American College of Obstetricians and Gynecologists Committee on Practice Bulletins-Gynecology. ACOG Practice Bulletin No. 119: Female sexual dysfunction. Obstet Gynecol. 2011;117(4):996-1007. Reaffirmed 2015. 16. Labrie F, Bélanger A, Pelletier G, Martel C, Archer DF, Utian WH. Science of intracrinology in postmenopausal women. Menopause. 2017 Jan 16. doi: 10.1097/GME.0000000000000808. 17. Archer DF, Labrie F, Bouchard C, et al; VVA Prasterone Group. Treatment of pain at sexual activity (dyspareunia) with intravaginal dehydroepiandrosterone (prasterone). Menopause. 2015;22(9):950-963. 18. Labrie F, Archer DF, Koltun W, et al; VVA Prasterone Research Group. Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. Menopause. 2016;23(3):243-256. 19. Berger L, El·Alfy M, Labrie F. Effects of intravaginal dehydroepiandrosterone on vaginal histomorphology, sex steroid receptor expression and cell proliferation in the rat. J Steroid Biochem Mol Biol. 2008;109(1·2):67· 80. 20. Labrie F, Luu-The v, Labrie C, Simard J. DHEA and its transformation into androgens and estrogens in peripheral target tissues: intracrinology. Front Neuroendocrinol. 2001;22(3):185·212. 21. Portman DJ, Gass ML; Vulvovaginal Atrophy Terminology Consensus Conference Panel Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Maturitas. 2014;79(3):349·354. 22. Galinsky AM, Waite LJ. Sexual activity and psychological health as mediators of the relationship between physical health and marital quality. J Gerontol B Psychol Sci Soc Sci. 2014;69(3):482-492.