ADHD-ers, skip to the end for the TLDR summary
The vulva is like many of us. At times she can be tough as hell (ever seen childbirth?) Other times she is like a delicate flower. She can be exquisitely sensitive to all kinds of changes or skin contact. If you don't treat her right, she might get irritated, angry, or downright vindictive. To top it off, once you start to lose estrogen from perimenopause, things can go downhill.
I often ask my patients who complain of new vulvar symptoms (itching, usually) what types of products they use... soaps/body washes, laundry detergents, panty liners. The answer I typically get is "Oh well I haven't changed anything, I have been using the same products for years."
Well, you might not have changed anything, but YOU may have changed.
With lower estrogen levels, inflammatory reactions are more likely to occur because estrogen can act as an anti-inflammatory in the body. With the menopausal decline, inflammatory responses can start popping up in places where they may not have before. That can include reactions to products on the skin.
Common offenders I see are T*de detergent (including the free and clear kind), @lways pantyliners, and anything by $ummers eve. I also sometimes find patients having reactions to condoms and certain lubricants - especially when they contain scents, flavors, or other additives.
Of course, not every itch is an allergy - itching can be a symptom of genitourinary syndrome of menopause (GUSM), also caused by the loss of estrogen in the area.
Itching can also be a sign of a more serious problem. Infections such as yeast or certain bacterial infections, inflammatory dermatologic conditions such as lichen sclerosis or lichen planus (important topics for another day), or even vulvar cancer.
It is crucial that if you are experiencing itching as a new symptom, you must get evaluated by a medical professional, ideally a gynecologist.
Once the "bad stuff" has been ruled out, then we get into troubleshooting and trying to fix the problem.
First and foremost, go and get yourself some local topical hormones! Most commonly vaginal estrogen comes in a cream, vaginal pill, or vaginal ring (for the FDA-approved versions), but there is also vaginal DHEA also known as Intrarosa, which gets converted into both estrogen and testosterone. These are by far the most effective treatments for GUSM, and I am a fan of using these treatments prophylactically for women in menopause. They are incredibly safe, with little downside.
Benefits include: increased vaginal moisture, increased vaginal and vulvar elasticity and tissue quality, decreased pain with penetrative sex, decreased urinary frequency, urgency, and incontinence, and importantly - reduced risk of urinary tract infections -- a potentially dangerous and even deadly problem!
While vaginal hormones may not cure all these ailments, they can be quite effective and help a great deal, with little downside. The label comes with a big warning, which is not based on very accurate information, and there is currently a movement to try to have the black box warning removed from vaginal local estrogen products. (there is a link at the bottom to sign a petition letter to the FDA from patients - help us out!!)
The other thing I recommend to my patients is trying to change some of their habits and products when it comes to vulvar and vaginal care.
Now while you may not have had a "routine" for the vulva and vagina prior, it's time to implement one!
First, any products that make contact with the vulva should be fragrance-free, and free of harsh chemicals, and any soaps or detergents should be GENTLE, or oil-based. That usually translates to "sulfate-free" on a label. (If you read the back ingredients, look for "sodium-laurel sulfate" or "sodium XXX sulfate" - that is a particularly harsh and common soap ingredient that can be quite stripping of the natural oils on the skin.) You may want to also apply this idea to all your soap as the rest of the skin tends to be drier and have less barrier protection as well in menopause.
Here are some of the products I recommend to patients on a regular basis:
Body wash:
Facial cleansers tend to be gentler, especially the simple dermatologic-ones. I like Cetaphil facial cleanser.
The one I use personally, SheaMoisture 100% Virgin Coconut Oil Body Wash, is more oil based and very moisturizing. Cleansing but super gentle on the skin. Please note, it does contain some fragrance so if you are prone to being extra sensitive this one may not be for you.
As far as how to wash, less is sometimes more. You can gently use your fingers with water or minimal body wash (such as the options listed above) to cleanse. Avoid scrubbing with anything harsh like a washcloth or firm loofa.
You should NOT wash inside the vagina - and certainly no douching as it can disrupt the vaginal pH and make you more prone to infection. Avoid scrubbing with anything such as washcloths or natural loofas as they can be too harsh on the skin.
Laundry Detergent - yes, these products can be irritants too! (Avoid fabric softeners, if possible)
I go back and forth between Seventh Generation EasyDose and Eco-me (linked below), depending on availability. Both are pretty effective.
Pantyliners and Pads
If you don't need them, try to avoid it. vaginal discharge is normal! But if you need the added protection, I recommend organic cotton liners and pads if possible. Here are a few options:
Incontinence Pads
Moisturizer... for the vulva and vagina.
In addition to twice weekly vaginal estrogen, if you are experiencing symptomatic vaginal dryness, non-hormonal options can be really helpful as well. Hyaluronic acid treatments has been shown in many studies to improve the symptoms of vaginal dryness. Other moisturizers like vitamin E show mixed results, so I tend to recommend the hyaluronic acid. Oil-based moisture is great for dry external skin and for use as a sexual lubricant.
Revaree by Bonafide is a fan-favorite. This little bullet-shaped suppository melts slowly in the entrance of the vagina, providing continual moisture over the course of a few days. It uses hyaluronic acid as the active ingredient.
Or you can give Replens a try. This hyaluronic acid suppository is more liquidy so may come out easier than the replens.
Finally, coconut oil is great for moisture and as a lubricant. You can put it everywhere! Vulva, legs, penis, frying pan... warning - not compatible with condoms!
Barrier protection: Armor for the vulva
If you sweat, swim a lot or have urinary incontinence, try not to sit in wetness as this can cause skin barrier disruptions or fungal infections. If you cannot avoid it or are very prone to these issues, try using ointment as a barrier protection when needed (i.e. during runs, or if you have frequent leakage). This can also help for runners who tend to get chafing.
A classic simple option without added ingredients. When we are dealing with the vulva, its nice to have a squeezable tube as opposed to an open tub for hygienic reasons
Yup - the same one you used on the baby. PS I was today years old when I realized A+D stood for vitamin A and vitamin D
This one contains zinc, which is a great barrier protectant. I recommend this one if you already have some skin barrier disruptions. This is often used for things like bed sores to help them heal, and is applicable to many other uses for healing skin in dark, moist areas.
SUMMARY
TLDR: As estrogen declines during perimenopause and menopause, your vulva can become extra sensitive, even to products you’ve used for years. This can lead to itching and irritation, often due to inflammatory reactions triggered by hormonal changes. But itching isn’t always harmless—it could signal more serious issues, so a visit to your gynecologist is a must. Once the big concerns are ruled out, (prescription) local vaginal hormones like estrogen cream can help keep things healthy and comfortable - talk to your doc about this as well. And it’s time to rethink your care routine — gentle, fragrance-free products (some of my fav options listed above) and no scrubbing allowed!
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