The Unending Indignities of ‘Vaginal Atrophy’

We wanted to share this great article from the NYTimes on menopause. At our practice we see many patients that are experiencing pelvic health issues related to menopause. We wanted to share this great article from the NYTimes on menopause.

Reprinted from the NYTimes. By Rachel E. Gross
Published Aug. 22, 2023

The Unending Indignities of ‘Vaginal Atrophy’
Besides causing offense, the phrase may contribute to the under-diagnosing of treatable problems associated with menopause.

When Heather Corinna started a Facebook support group in 2019 for people going through menopause and perimenopause, one phrase came up again and again. Members of the group had read about it online, heard it from their doctors and seen it in their medical notes. “Everybody had a bad reaction to it,” said Mx. Corinna, a queer sex educator and founder of the sex education site Scarleteen. The phrase? Vaginal atrophy.

Amid the many unfamiliar terms and bodily changes that people were facing, “vaginal atrophy” seemed to encapsulate a host of fears around sexuality and aging. “I mean, atrophy,” said Mx. Corinna, 53, who is nonbinary. “Like, I’m getting older, bodies change. My elbows certainly don’t look or act like they used to, but you don’t hear anybody talking about my elbow atrophy.”

Officially, the phrase was phased out years ago. In 2013, the Menopause Society and the International Society for the Study of Women’s Sexual Health convened a panel of medical experts to replace the term, which was increasingly seen as outdated. Atrophy “has negative connotations for midlife women,” they wrote. Also, they added, “vagina” was “not a generally accepted term for public discourse or the media.”

But as Mx. Corinna has learned, the phrase continues to haunt the medical literature, as well as the health and medical care of people going through menopause. In medicine, “atrophy” commonly refers to a loss or thinning of tissue. In this case, it refers to tissues that rely on estrogen, and so become thin and lose elasticity in menopause, when levels of the hormone decline. But the vagina and vulva aren’t the only body parts affected by these hormonal changes; the urethra and bladder also require estrogen to function properly. To many patients, the focus on the vagina alone makes it seem as if all their genital symptoms are being sexualized. In reality, problems that are often associated with penetrative intercourse — dryness, irritation, thinning of tissue — also cause discomfort and pain with other everyday activities. Dr. Stephanie Faubion, director of the Mayo Clinic Center for Women’s Health, hears from patients who find it difficult to sit in the car, put on jeans or wipe after going to the bathroom. But because estrogen therapy is often marketed primarily for sexual pain, many patients don’t realize that these symptoms can also be addressed with vaginal estrogen.
“It is weird that there just is a focus on the sex part of it,” said Dr. Faubion, who is also the medical director of the Menopause Society. “These are not lifestyle drugs, like Viagra. They’re treating many more symptoms other than having this just be about sex.”

An over-focus on the vagina also obscures the fact that urinary problems — including incontinence, increased frequency of urination and urinary tract infections — are often related to menopause. For many, these symptoms can be just as bothersome as genital ones: U.T.I.s are responsible for 15 percent of hospitalizations of older adults, and can lead to delirium or even
death.

“I spent my 20s and early 30s in a nonstop urinary tract infection, I can’t go back to that,” said Mx. Corinna, who is the author of the book “What Fresh Hell Is This? Perimenopause, Menopause, Other Indignities, and You.” “If something changes with my vulva and I need to learn different ways to have sex or I need to sit on a donut, I can deal with that. But I can’t deal with having a U.T.I. all the time anymore.”

In other words, the phrase “vaginal atrophy” wasn’t just potentially offensive, it was also clinically misleading. Millions of women and other people going through menopause go undiagnosed for treatable symptoms, said Dr. James Simon, a clinical professor of obstetrics and gynecology at George Washington University School of Medicine and Health Sciences and a member of the panel reconsidering the term. “We felt that one of the reasons was bad terminology,” he said.

In 2014, the panel agreed on a new term incorporating these insights: genitourinary syndrome of menopause, or G.S.M. It wasn’t particularly catchy, but it brought the urinary system to the party, and unlike the term vaginal atrophy, it “didn’t have shame, wasn’t something that women did wrong or brought upon themselves,” Dr. Simon said. “It was just a natural process of aging that had a constellation of symptoms that could be lumped together as a syndrome.” There was precedent for rebranding a genital condition to make it more palatable to patients. In 1992, the National Institutes of Health replaced the term impotence with erectile dysfunction, or E.D. The reasoning was similar: Impotence was considered to be disparaging and imprecise, and was thought to imply that the condition was mainly psychological, adding to barriers in communication between patients and health care providers.

Yet while E.D. has become firmly established in both the medical and popular lexicon, G.S.M. hasn’t had the same success. Vaginal atrophy is still the primary term used by most estrogen therapy companies, as well as many providers. “I don’t know that it’s commonly known,” said Dr. Faubion, who often finds herself having to explain the term to colleagues.

Even doctors who don’t want to subject their patients to the term can find it difficult to avoid. Dr. Robin Noble, an obstetrician-gynecologist in Portland, Maine, tries to focus her conversations with patients on specific symptoms such as dryness and irritation. Yet when she prescribes vaginal estrogen, she still has to choose “vaginal atrophy” from a drop-down menu of diagnoses on her hospital computer system, and patients might end up seeing it in their medical notes. “I can’t avoid it entirely,” she said.

Only a decade ago did gynecology shift from being a male-dominated field to one in which providers were primarily female. Given that history, it is perhaps unsurprising that much of the terminology feels archaic: Consider the phrases ovarian failure, incompetent cervix and senile uterus (really).

In OB-GYN literature, women ages 15 to 49 are often categorized as “reproductive-aged” or “of reproductive age.” Going through menopause marks “the end of the childbearing phase of a woman’s life,” as the Menopause Society website puts it, and “the end of their reproductive years,” according to the World Health Organization. (Both are better than the choice of wording in one 2015 paper: “the end of reproductive competence.”)

Besides being vague — there’s quite a difference between a 15-year-old and a 49-year-old — these phrases carry an implicit assumption that all women will, or should, reproduce. Such language can be jarring to people who can’t have children or choose not to, and to those who don’t want to be defined by their reproductive capacity. It has also caused some people to believe that they can’t get pregnant in perimenopause; they can.

It may be more useful, and less presumptuous, to define menopause simply by what is happening inside your body, said Dr. Judith Joseph, a psychiatrist at NYU Langone Health who is on the medical board of Let’s Talk Menopause, a nonprofit organization. “Your ovaries are no longer ovulating,” Dr. Joseph said she tells her patients. “That has a totally different sound compared to ‘reproductive years,’” she said, adding, “You’re teaching people about what’s happening in their bodies, not what they’re capable of doing.”

Of course, meanings change over time, and depend on who is holding the medical chart.
Many people consider “vaginal atrophy” derogatory because there is no equivalent term for male genitals. While penises and testicles also shrink with age, medicine rarely describes them as atrophying, “and so no woman wants that diagnosis, either,” Dr. Faubion said. But testicular atrophy is not unheard-of; the term can describe genital shrinkage after steroid use, prostate cancer treatment or testosterone-blocking hormones for gender affirmation.

For some doctors, atrophy is a neutral term that has no bearing on the value and dignity of the patient before them. Dr. Kathleen O’Banion, an OB-GYN and faculty member at Cooper University Hospital in New Jersey, remembers using the phrase in a lecture on estrogen loss and sexual function 30 years ago. During her talk, a sex therapist in the audience raised her hand and objected to the language.

Dr. O’Banion was taken aback. “I saw that the term ‘atrophy’ upset her, but it had no such meaning for me,” she said in an email. In her view, “an atrophic labia is as wonderful and deserving of my concern and care” as any other.

Harriet Lee-Merrion Photo Credit