By Dr. John A. Robinson, NMD
Menopause changes much more than a woman’s menstrual cycle. It changes how she feels in her own body. Vaginal dryness develops, intimacy becomes uncomfortable, urinary symptoms become more frequent, and many women begin avoiding sexual activity because they anticipate pain. Too often, they are told these symptoms are simply part of getting older.
I don’t believe women should accept that answer.
At The Hormone Zone®, we believe healthy vaginal tissue is an essential part of healthy aging. Vaginal health affects intimacy, urinary function, pelvic comfort, confidence, and overall quality of life. Most importantly, these symptoms are usually treatable when we address the underlying biology rather than simply recommending another lubricant.
As estrogen and testosterone decline during menopause, the vaginal tissues become thinner, less elastic, less vascular, and less lubricated. Collagen production decreases, blood flow diminishes, the vaginal pH rises, and the normal protective microbiome begins to change. These changes are collectively known as Genitourinary Syndrome of Menopause (GSM), previously called vaginal atrophy.
Unfortunately, many women develop another condition as these changes progress—secondary vaginismus. Vaginismus is an involuntary tightening of the pelvic floor muscles surrounding the vaginal opening. It is not psychological weakness, nor is it something a woman consciously controls. It is a protective reflex. When penetration repeatedly causes discomfort, the pelvic floor begins tightening in anticipation of pain. Over time, pain leads to muscle guarding, muscle guarding makes penetration more difficult, and penetration becomes even more painful. Fortunately, this cycle can almost always be interrupted with the proper treatment strategy.
One of the concepts I frequently teach my patients is that every tissue in the body requires both the proper biological environment and appropriate mechanical stimulation. Bones require weight-bearing exercise. Muscles stay healthy because we use them. Tendons remodel under appropriate loading. Vaginal tissue behaves much the same way.
Research has shown that postmenopausal women who continue regular vaginal penetration often demonstrate less severe vaginal atrophy and maintain better vaginal function than women who become sexually inactive. While penetration alone does not correct the hormonal changes responsible for GSM, it appears to help preserve vaginal caliber, elasticity, flexibility, and comfort with penetration.
For women who are not sexually active, or who are rebuilding comfort after menopause, surgery, or pelvic pain, a medical-grade vaginal dilator provides the same principle of gentle mechanical tissue loading. The goal is not sexual stimulation. The goal is maintaining healthy tissue mechanics while teaching the pelvic floor muscles to relax rather than contract.
My Treatment Recommendations
After caring for thousands of women over the past two decades, I have found that the best results come from treating every aspect of vaginal health—not simply addressing dryness.
1. Optimize the Hormonal Environment
Everything begins with hormone optimization.
Healthy vaginal tissue depends on adequate estrogen and testosterone. In my clinical experience, I achieve the most consistent improvements in vaginal health by optimizing systemic estrogen and testosterone with bioidentical pellets or injections, when clinically appropriate. By restoring physiologic hormone levels, many women experience improvements in vaginal blood flow, lubrication, tissue integrity, sexual desire, urinary symptoms, and overall well-being.
While creams, gels, and patches have an important role in hormone replacement therapy, my experience has been that optimizing systemic hormone levels with pellets or injections, combined with targeted local therapy, often provides more complete restoration of vaginal health. There are currently no FDA-approved testosterone patches for women, making individualized testosterone replacement an important consideration for appropriately selected patients.
2. Restore the Vaginal Tissue Locally
Even with optimized systemic hormones, I frequently prescribe a compounded vaginal estradiol and DHEA cream to directly restore the vaginal tissue.
My typical protocol is:
- Every other day initially until symptoms improve.
- One to two applications per week for long-term maintenance.
This local therapy complements systemic hormone optimization by improving epithelial thickness, increasing lubrication, enhancing local blood flow, restoring a healthier vaginal pH, and supporting the normal vaginal microbiome.
3. Maintain Healthy Tissue Through Regular Mechanical Stimulation
Healthy tissue responds to healthy use.
I encourage regular, comfortable vaginal penetration approximately two to three times each week, either through sexual intercourse or with a medical-grade vaginal dilator. Regular mechanical stretching helps preserve vaginal elasticity, maintain vaginal caliber, improve tissue mobility, and reduce the pelvic floor muscle guarding that contributes to vaginismus.
For women requiring a dilator, my preferred recommendation is the Intimate Rose® Medical-Grade Silicone Vaginal Dilator System. I recommend it because of its high-quality medical-grade silicone construction, graduated sizing, and exceptional comfort. It is an excellent option for women who are rebuilding confidence and comfort with penetration.
4. Restore Pelvic Floor Function
When chronic pelvic floor tension has developed, pelvic floor physical therapy can be one of the most effective parts of treatment. Specialized therapists help women learn to relax the pelvic floor muscles, improve muscle coordination, and eliminate the protective muscle guarding that perpetuates painful intercourse.
5. Advanced Regenerative Medicine
For selected women with significant tissue degeneration, persistent GSM symptoms, or diminished sexual function despite comprehensive hormone optimization, we may incorporate regenerative therapies, including the O-Shot® utilizing VittiPure® and, in appropriate cases, regenerative birth tissue-based therapies.
Our philosophy is not that these procedures replace hormone optimization, but that they may complement it by supporting the body’s natural healing response and tissue remodeling. At The Hormone Zone®, regenerative medicine is always integrated with systemic hormone optimization, local vaginal hormone therapy, pelvic floor rehabilitation, and mechanical tissue restoration.
For the appropriate patient, these advanced regenerative therapies become another tool that helps restore healthier tissue, improve comfort, and enhance overall sexual wellness as part of a comprehensive treatment strategy.
The Hormone Zone® Method
There is rarely a single treatment that restores vaginal health. The best outcomes occur when the entire biological environment is optimized while simultaneously restoring healthy tissue mechanics.
My philosophy is simple:
- Restore healthy systemic estrogen and testosterone levels.
- Rebuild the vaginal tissue directly with compounded estradiol and DHEA.
- Maintain healthy tissue through regular vaginal penetration or medical-grade dilator therapy.
- Restore normal pelvic floor function.
- Incorporate regenerative medicine for appropriately selected patients when additional tissue restoration is needed.
When we address all of these components together, we are no longer simply treating vaginal dryness—we are restoring healthy tissue biology, preserving function, and improving a woman’s confidence, intimacy, urinary health, and quality of life.
Women should never believe that pain, dryness, or loss of intimacy are inevitable consequences of menopause. They are often signs that the vaginal tissue is asking for help.
At The Hormone Zone®, our goal is to restore that tissue, optimize the hormonal environment that supports it, and help women continue living vibrant, healthy, fulfilling lives through every stage of aging.
References
Leiblum SR, Bachmann GA, Kemmann E, Colburn DW, Swartzman L. Vaginal atrophy in the postmenopausal woman: The importance of sexual activity and hormones. JAMA. 1983;249(16):2195-2198.
The North American Menopause Society. The 2020 Position Statement on Genitourinary Syndrome of Menopause.
Kingsberg SA, et al. Genitourinary Syndrome of Menopause: Evaluation and Management. Mayo Clinic Proceedings.
