Why Your Vaginal Exam Doesn't Stop at Menopause

Written by: Meredith Paci Functional Health Coach 

I was talking to one of my mentees about a client of hers who had this exact experience, and honestly, it still gets me fired up every time I hear it. I find it atrocious.

I told her about a client of mine who had the identical experience. My client went in for her women's health exam and never got a pelvic exam. The reason: "you're in menopause." Turns out my client hadn’t had a pelvic exam in YEARS! 

She may be in menopause. She still has a vagina, a urethra, a bladder, a vulvar vestibule , etc…

I hear some version of this constantly. It's the same every time: once a woman is past reproductive years, there's nothing left down there worth checking. And if she happens to mention about painful sex then we just hand her lubrication which is just lazy.

Now, I am going to discuss a lot about menopause but what is shocking to most is that this tissue doesn't wait for menopause to start changing. It starts shifting as early as perimenopause, which for a lot of women means their 30s. The "nothing to check" assumption isn't just wrong at 55, 65 or 85. It's wrong a decade or more earlier than most women think to ask about it.

I've seen this pattern enough times across clients in perimenopause and postmenopause that it's worth addressing directly, because it's not a one-off scheduling shortcut. It reflects an assumption that once a woman is past reproductive years, or even just approaching them, the vagina and urethra stop being clinically relevant tissue. That assumption is wrong, and there's now a formal clinical guideline that says so.

What's happening physiologically

Vaginal and urethral tissue is estrogen-dependent, and it's androgen-dependent too. Both hormones matter here, not just estrogen, which is where most of the public conversation stops. As estrogen and androgens decline during the menopause transition and stay low afterward, that tissue changes: it thins, loses elasticity, loses the folds (rugae) that give the vaginal walls their normal texture, and becomes more fragile and more susceptible to irritation and infection. The urethra and bladder tissue are affected the same way, which is part of why urinary symptoms cluster with vaginal symptoms at this life stage.

The clinical term for this cluster is genitourinary syndrome of menopause, or GSM. It replaced the older term "vulvovaginal atrophy" because that older term only captured the vaginal piece and missed the urinary piece. GSM covers both: vaginal dryness, burning, pain with sex, and urinary urgency, frequency, and recurrent UTIs.

And shockingly, none of this tissue is just there for sex. It's functional tissue with real jobs: the vagina and vulva play a role in arousal and childbirth, the urethra handles urination, the pelvic floor supports continence, and the clitoris, which almost nobody is actually checking, has its own version of this same problem. As estrogen and androgens decline, the clitoral hood can adhere to the glans, a condition called clitoral phimosis. It's been documented in roughly 23 percent of women presenting for sexual dysfunction, most commonly linked to postmenopausal atrophy, and it's a real, physical cause of lost sensation and pain, not something in your head. Most exams don't retract the hood to even look. Research on testosterone's exact role in severity is still mixed and not fully settled, but treatment with vaginal estrogen has been shown in case series to improve clitoral sensation and function.

None of this is rare. GSM is commonly cited as affecting up to 70 percent of postmenopausal women to some degree. What's more solid than any single prevalence number is this: GSM does not reliably show up as something a woman can self-diagnose from symptoms alone, and it does not reliably resolve without recognition and treatment. It also doesn't go away because a clinician doesn't look for it.

What the 2025 guideline actually says

In 2025, the American Urological Association released the first comprehensive clinical guideline on GSM, developed jointly with the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) and the American Urogynecologic Society (AUGS).

Two points from that guideline matter most for this conversation. First, patients presenting with GSM symptoms should undergo a genitourinary exam, specifically to check for vaginal skin thinning, loss of vaginal rugae, urethral prolapse, and changes to the labia minora. Second, and arguably the most important point because not every person is going to have symptoms that they feel are ‘necessary’ to be treated….clinicians are directed to educate patients on the connection between declining sex steroid hormones and these genitourinary changes, and to evaluate for co-existing conditions rather than treating the symptoms as an isolated, minor complaint.

In plain terms: skipping the exam because a patient is postmenopausal runs against the guideline, not with it. This is now a documented clinical standard, not just a clinical opinion.

The UTI connection, and where the evidence is strong

Recurrent UTIs are one of the more disruptive GSM symptoms, and they're often treated in isolation with repeated rounds of antibiotics rather than addressed at the underlying tissue level. That pattern matters more than it gets credit for, because this isn't just a comfort issue.

Untreated, a UTI can progress to urosepsis, a bloodstream infection with a mortality rate commonly cited between 20 and 40 percent once it develops. In adults over 65, roughly 30 percent of sepsis cases start as a urinary tract infection, and women show higher age-adjusted urosepsis mortality than men in CDC trend data spanning 1999 to 2020. This is not "just a UTI," and treating it like a minor, recurring inconvenience misses what's actually at stake for a lot of women in this age group.

Here the evidence for treatment is genuinely strong, not just directionally suggestive. Low-dose vaginal estrogen, applied locally, has randomized controlled trial support for reducing recurrent UTI frequency in postmenopausal women. The first RCT on this, published in the New England Journal of Medicine in 1993, compared intravaginal estriol to placebo in postmenopausal women with a history of UTIs and found a clear benefit for the treatment group. Since then, pooled analysis across placebo-controlled trials has shown roughly a 2.5-fold reduction in UTI risk with vaginal estrogen compared to placebo.

On safety: local vaginal estrogen is a different exposure profile than systemic hormone therapy. It works locally on vaginal and urethral tissue with minimal systemic absorption. A 2019 systematic review covering RCTs and observational studies found no increased risk of endometrial hyperplasia or endometrial cancer in patients using low-dose vaginal estrogen without added progestogen. This distinction matters because a lot of women, understandably given how HRT has been covered in the media over the years, hear "estrogen" and assume the same risk profile as systemic therapy. It isn't the same conversation.

Vaginal DHEA (prasterone) is another option worth knowing about, since it addresses the androgen side of this directly. It's FDA-approved specifically for moderate to severe pain with sex related to GSM, and it works locally, letting genital tissue convert DHEA into estrogen and testosterone on site with minimal systemic absorption.

What to ask for at your next appointment

If you're in perimenopause or beyond and it's been a while since anyone actually looked, not just asked, here's what to bring up directly with your provider:

Ask for a pelvic exam that includes an assessment for GSM specifically, not just a pap smear. You do NOT need to be symptomatic. If you do have vaginal dryness, pain with sex, or recurrent UTIs, name all three even if you think they're unrelated. Ask specifically about clitoral sensation or pain, since that's almost never assessed and almost never volunteered. Ask whether low-dose vaginal estrogen or vaginal DHEA is appropriate for you, and ask your provider to walk you through the difference between local treatment and systemic hormone therapy if that distinction hasn't been made clear. Please know that if you are a candidate for systemic you can use both systemic and local. If a provider tells you there's nothing to check because of your menopause or if you aren’t looking to get pregnant ‘don’t worry yourself about it’, you can reference the 2025 AUA/SUFU/AUGS guideline directly. 

None of this makes the exam itself more comfortable. It's still your body, still a potentially vulnerable experience for many, you are still allowed to feel exactly as uncomfortable as you do. But skipping the conversation, skipping the inquiry, doesn't make that discomfort go away. It just removes the opportunity to catch tissue changes before they progress into something far more serious, in some cases a bloodstream infection with a mortality rate as high as 40 percent.

If you're a coach and this is the level of clinical reasoning you want in your own case work, not just the surface-level protocol version, this is the kind of thing we cover and support inside our mentorship program. [REQUEST A CALL HERE TO LEARN MORE]

If you're navigating this in your own body and want a plan built around you, symptoms, history and your desired future instead of guessing at it alone, [INQUIRE ABOUT A 1:1 STRATEGY SESSION HERE] and we'll build one together.

If you have a question of your own, the anonymous form that started this entire series is still open. Ask Fortify {HERE} I already have the next one queued up and I cannot wait to get into it!

Meredith Paci is the co-founder of Fortify Health Coaching. I am not a licensed medical provider. The content in this post is educational and does not constitute medical advice or a patient-provider relationship. If you are considering hormone therapy, work with a qualified and well experienced provider who will assess your individual history.