In 2019, when Heather Corinna opened a Facebook support group for people going through menopause and perimenopause, one term kept popping up. Members of the group had read about it online, heard their doctors talk about it, and seen it in their medical records. “Everyone reacted badly,” says Corinna, who is a queer sex educator and founder of the sex education website Scarleteen.
The term in question: vaginal atrophy.
Amidst the many terms and body transformations people were experiencing, “vaginal atrophy” seemed to encapsulate a multitude of concerns surrounding sexuality and aging. “After all –atrophy!”, says Corinna, who is 53 years old and non-binary.
“I know I’m getting older and the body is changing. My elbows don’t look the way they used to and they don’t work like they used to, but you won’t hear anyone say I have elbow atrophy.”
The term was officially abandoned in the US years ago. In 2013, the Menopause Society and the International Society for the Study of Women’s Sexual Health tasked a panel of medical experts to replace the term, which is increasingly seen as outdated. The organizations wrote that the term “carries negative connotations for middle-aged women.” Furthermore, they added, “the word ‘vagina’ is not a widely accepted term in public discourse or the media.”
But, as Corinna discovered, “vaginal atrophy” continues to haunt the medical literature, as well as the medical and health care of people going through menopause. “Atrophy” in medicine is generally used to indicate a loss or thinning of tissue. In the case here, it refers to tissues that depend on estrogen, so they become thinner and lose elasticity in menopause, when hormone levels decrease. But the vagina and vulva aren’t the only parts of the body affected by these hormonal changes; the urethra and bladder also require estrogen to function properly.
For many patients, the exclusive focus on the vagina makes it seem like all of their genital symptoms are being sexualized. In fact, problems that are often associated with penetrative intercourse – dryness, irritation, tissue thinning – also cause discomfort and pain with other everyday activities.
Stephanie Faubion, director of the Women’s Health Center at the Mayo Clinic, receives reports from patients who have difficulty sitting in a car, putting on jeans, or drying themselves off after going to the bathroom. But because estrogen therapy is often promoted primarily for sexual pain, many patients do not realize that these symptoms could also be treated with vaginal estrogen.
“It’s strange that there’s this focus only on the sexual part of the problem,” says Faubion, who is also the medical director of the Menopause Society. “We are not talking about so-called ‘lifestyle’ medications, such as Viagra. They are medications that treat many other symptoms, they are not limited to the sexual issue.”
Excessive focus on the vagina also obscures the fact that urinary problems — including incontinence, increased urination and urinary tract infections — are often linked to menopause as well. For many women, these symptoms can be just as bothersome as the genitals: Urine infections account for 15% of hospitalizations in older adults and can lead to delirium and even death.
“I spent my late 20s and early 30s with an ongoing urinary tract infection,” says Corinna, who is the author of the book “What Fresh Hell Is This? Perimenopause, Menopause, Other Indignities, and You.” Perimenopause, menopause, other indignities and you, in Portuguese). “I can’t face that again.”
The term “vaginal atrophy” wasn’t just potentially offensive — it was also clinically misleading. Millions of people who go through menopause have treatable symptoms that are never diagnosed, says James Simon, clinical professor of gynecology and obstetrics at the George Washington University School of Medicine and Health Sciences and a member of the panel that reevaluated the term. “We think one of the reasons for this is inappropriate terminology.”
In 2014 the panel agreed on a new term that incorporates these ideas: genitourinary menopausal syndrome, or GMS. It’s not exactly nice, but it includes the urinary system, and, unlike the term “vaginal atrophy”, “it doesn’t contain the idea of shame, of something that women did wrong”, points out Simon.
There was a precedent for changing the term for a genital condition to make it more acceptable to patients. In 1992 the US National Institutes of Health replaced the term “impotence” with “erectile dysfunction”, or ED. The reasoning was similar: “impotence” was seen as an imprecise and derogatory term, implying that the problem was mainly psychological in origin. This increased barriers to communication between patients and doctors.
But while ED has firmly established itself in the medical and popular lexicon, the same has not happened with SGM. “Vaginal atrophy” is still the term most used by most estrogen therapy firms and also by many doctors. “I don’t think everyone knows the term ‘SGM,’” says Faubion, who often has to explain it to his colleagues.
In the medical literature of obstetrics and gynecology, women aged 15 to 49 are often classified as being “of reproductive age”. Going through menopause marks “the end of the reproductive years of a woman’s life”, says the North American Menopause Society and “the end of the reproductive years” of women, according to the WHO (World Health Organization). (Both options are better than the phrase used in a 2015 scientific paper: “the end of reproductive competence.”)
That kind of language can be off-putting. Furthermore, it has led some women to think that they cannot get pregnant when they are in perimenopause, which is not the case.
It can be helpful and less presumptuous to define menopause simply by what’s happening in your body, says Judith Joseph, a psychiatrist at NYT Langone Health and a member of the medical board of the nonprofit Let’s Talk Menopause.
“Your ovaries are no longer ovulating,” Joseph tells his patients. “That sounds completely different from talking about ‘reproductive years’.”
Translation by Clara Allain
