The Menopause Symptom That Shocked Me The Most

I had no idea this would happen.

By
Published July 02, 2026
Illustration of a stylized person bending forward beside a blooming plant releasing heat-like shapes, symbolizing menopause symptoms
Naomi Elliott

When I was approaching puberty, my mother barely divulged anything about menstruation — except to give me a pamphlet to read that was published by a sanitary napkin company. She left the room, and told me to ask any questions later. Of course I didn’t, as we were both too embarrassed to talk about it. Times changed when my daughter’s pediatrician told her to wear tampons so she wouldn’t miss a day of summer camp.

My mother never even mentioned menopause. If she had, I might have understood her mood swings. My daughter took required sex-ed classes in school, and one day she asked me if I “had” menopause. I asked her how she’d heard about it. “From Marge on The Simpsons,” she replied.

Although most of us have become much more open today about the hormonal changes in our female bodies, I was bewildered by my earliest symptoms of perimenopause. My male OB/GYN completely missed what was causing my itching down below. When it comes to perimenopause and menopause, hot flashes and insomnia seem easier to talk about than vaginal dryness — known medically as vaginal atrophy or genitourinary syndrome of menopause (GSM).

But it was pain during intercourse that surprised me the most.

“The earliest signs are subtle,” says Dr. Jessica Shepherd, board-certified gynecologist and menopause expert, author of "Generation M" and founder of Modern Meno. Her mission is to take the mystery out of menopause and replace it with clarity.

At first, women often notice vaginal dryness, irritation or burning, discomfort or pain during sex. Other symptoms can include urinary urgency, mild leakage, burning with urination, a watery discharge, or bleeding after intercourse.

“Without estrogen, the lining of your vagina can become thinner and less stretchy. Your vaginal canal can also narrow and shorten,” reports Cleveland Clinic.

Although we think of estrogen hormone levels decreasing in perimenopause and menopause, it can also occur as a result of certain cancer treatments, surgical removal of ovaries or during breastfeeding. A medical diagnosis should be done by your doctor, who can perform a pelvic exam, a Pap smear, and a urine test.

“Many women are surprised by how early these symptoms can show up, often in their 40s,” says Dr. Shepherd. “It’s very common, but often under-discussed.” She estimates that 50 to 70 percent of women experience symptoms related to vaginal atrophy in menopause.

WHY DOES THIS HAPPEN?

When we’re in our childbearing years, the hormone estrogen keeps our vaginal tissue healthy and supple. But as we enter perimenopause and menopause, our estrogen levels begin to decline, causing our vaginal tissue to thin and receive less natural lubrication and blood flow.

“Estrogen also helps maintain a healthy vaginal pH,” says Dr. Shepherd, referring to a figure from chemistry that measures acidity or alkalinity. With less acidity, symptoms like dryness and irritation can occur. Urinary infections also can happen.

HOW TO TREAT VAGINAL ATROPHY

Dr. Shepherd suggests different options, depending on how severe your symptoms are. “Treatment should be personalized,” she advises. “View this as treatable, not something to simply tolerate.” These options should be discussed with your gynecologist.

  • Over-the-counter vaginal moisturizers and lubricants when symptoms are subtle or mild.
  • Vaginal estrogen creams, tablets, or rings, one of the most effective and helpful ways because it directly targets the tissue through vaginal insertion.
  • Hormone Replacement Therapy (HRT) for severe symptoms of menopause. This can restore thickness and elasticity.
  • In certain cases, non-hormonal prescription treatment or energy-based therapies (lasers and radiofrequency).

Women who decide to go on Hormone Replacement Therapy may find their symptoms less severe, but again this is something to discuss with your doctor, who will explain the risks and benefits. “Estrogen doesn’t always provide enough support to the vaginal tissue,” says Dr. Shepherd, and sometimes, even with HRT, local vaginal estrogen needs to be added.

CAN VAGINAL ATROPHY BE PREVENTED?

Unfortunately, prevention may not be possible, according to Baylor Health. But here are some suggestions to keep your vaginal tissues as healthy as possible:

  • Don’t smoke, as it may impair blood circulation and make your body’s natural estrogen less effective.
  • Regular sexual activity enhances blood flow to the vagina. The expression “use-it-or-lose it” is true. The vagina is made of smooth muscle layers, and like other muscles in our body, it needs exercise to remain healthy. This piece of medical advice might be the most enjoyable of all — with the added benefit that sexual activity can also lower blood pressure, enhance your immune system, raise self-esteem, lower stress and anxiety, and give you a better night’s sleep. A win-win.

Candy Schulman’s essays, health, and travel pieces have appeared in AARP, The New York Times, The Washington Post, Next Avenue, Oldster, Parents, Travel & Leisure, among others. She is a creative writing professor at the New School in New York City and a private writing coach. Learn more at candyschulman.com.