So many middle-aged women suffer pain because they’re too ashamed to talk about their intimate area. Now pharmacist LAURA DOWLING reveals the little-known condition that causes it – and the simple cure

Laura Dowling is a pharmacist, health advocate, and founder of fabÜ health supplements. She’s widely recognised as the Fabulous Pharmacist to her over 300,000 Instagram following. With over two decades of experience in community pharmacy, she has become one of Ireland’s most trusted voices in women’s health.

Her debut book, Love Your Vulva, reflects her mission to tackle taboo health topics with honesty and compassion. The book is positioned as a comprehensive, stigma-free guide to women’s health, empowering readers to better understand and care for their bodies.

This extract here, from Chapter 10, Love Your Vulva, begins with the story of a 73-year-old woman who suffered in silence until Dowling intervened, highlighting how older women often feel invisible in healthcare. The chapter explores the role of estrogen in women’s bodies and the profound changes triggered by its decline during perimenopause and menopause.

THE STORY THAT CHANGED EVERYTHING

I’ve told you why I started Viva La Vulva and wrote this book, but what gave me the push to go all in was one unforgettable woman.

She was in her 70s and came into my pharmacy for her third tube of Canesten Thrush Cream in just a few weeks.

I knew something wasn’t right, so I gently asked her if she’d like a private chat.

What she described wasn’t thrush but severe vaginal dryness. Sitting hurt; wiping caused tiny cuts. She’d resorted to spraying herself with water after going to the loo just to avoid the pain. She’d also given up cycling years ago, even though it used to be her main enjoyable form of exercise, and she hadn’t had sex with her husband in over a decade.

The skin on her vulva was raw and broken.

She needed urgent help: estrogen cream and a vaginal estrogen pessary. When I told her that she needed to get examined by her doctor, she asked, “Why would anyone want to look at my 73-year-old vagina?”

That broke my heart.

Too many women feel invisible and unworthy of care simply because of their age.

Thankfully, with my encouragement, she went to see her doctor. Three weeks later, she was back, pain-free, smiling, and ready to dust off her bike. After four months, she was enjoying intimacy with her husband again.

Every Christmas since, I’ve received a card from him addressed to “My Favourite Pharmacist”.

THE REVOLUTION WILL BE MOISTURISED

If you allow your vagina to become dry and neglected, it’s only a matter of time before it gets sore, irritated, and unhappy. Your vulva can lose its shape and colour, and can even turn pale and greyish. Your clitoris can shrink due to the drop in estrogen. And when that happens? Orgasms get harder to reach, and libido takes a nosedive.

But there’s good news. Vaginal estrogen, whether a cream or pessary, can bring it all back to life.

It can plump up your clitoris, restore your vulva’s healthy pink glow, and make sex  pleasurable again. But this isn’t just about sex; it’s about comfort, confidence, and reconnecting with your body.

Let’s be honest: if men’s penises were drying up, shrinking, and becoming unfit for purpose, it would be a national emergency. There’d be creams in vending machines at the gym, pub, and petrol station. News headlines. Campaigns. Urgency.

But we don’t get that, so we have to make the noise ourselves.

Educate, share, and support each other. Looking after your vulva is smart, strong, and revolutionary.

ESTROGEN: THE MASTER REGULATOR OF THE FEMALE BODY

Girls and women have estrogen receptors all over their bodies, from the tops of their heads to the tips of their toes. From puberty, these receptors are flooded with estrogen. It regulates the menstrual cycle, drives breast development, and causes the physical changes associated with the transition from girl to woman.

However, the role of estrogen extends beyond these functions. It influences the reproductive tract, urinary tract, heart and blood vessels, bones, skin, hair, mucous membranes, pelvic muscles, and brain. This is why the perimenopause and menopause stages can profoundly affect women.

WHEN ESTROGEN DROPS

When estrogen levels fluctuate or decline, it can impact every part of our bodies. During perimenopause, when levels drop, women may experience irregular periods that eventually stop altogether. These periods can vary, becoming either lighter or heavier in intensity.

Alongside these changes, women may face increased vaginal inflammation and more intense cramps.

Other physical symptoms may include aching joints, pain, and a frozen shoulder.

Some women might also develop digestive issues, food intolerances, or bloating as their gut microbiome (the community of bacteria that live in the digestive system) undergoes changes during this phase.

This time can also be psychologically challenging, with symptoms such as irritability, brain fog, rage, fatigue, low mood, panic attacks, and anxiety. In this chapter, however, we will focus on how these hormonal changes affect the pelvic area.

ESTROGEN & YOUR VULVA

Your pelvic area is a hub filled with estrogen receptors (tiny structures that respond to the estrogen hormone). This region includes your bladder, bowel, uterus, vagina, urethra, vulva, and pelvic floor – essentially, all of your crucial female anatomy. During perimenopause and menopause, these receptors do not receive sufficient estrogen, which can lead to changes in your body.

UNDERSTANDING GSM

As women go through perimenopause and transition into menopause, the decline in estrogen levels can have a profound impact on the pelvic floor, vulva, vagina, and urinary tract.

These changes are not just superficial or temporary. They reflect more serious structural and functional shifts that can frequently be overlooked. One key condition that can arise is known as genitourinary syndrome of menopause, or GSM.

While it may sound clinical, understanding GSM is crucial because it can profoundly affect everyday comfort and quality of life.

WHAT IS GSM?

GSM refers to a collection of symptoms and changes in the vulva, vagina, urethra, and bladder that occur during perimenopause and after menopause.

It’s not a single condition but a syndrome that can appear in various ways and intensities from one woman to another.

Around 80% of women experience some form of GSM. It can affect the labia, clitoris, vaginal tissues, and pelvic floor.

Early understanding and management are essential because it’s chronic and progressive if left untreated.

WHAT ARE THE SYMPTOMS?

Symptoms of GSM can include vaginal dryness, irritation, itching, burning, and pain during sex. Many women also report urinary symptoms such as urgency, frequency, burning with urination, or recurrent urinary tract infections.

The vulva and vagina may show changes in appearance, such as thinning of the tissue and a loss of elasticity. Some women experience many of these symptoms, while others may only notice one or two. The variability doesn’t make it any less critical. Every woman deserves to feel informed and supported.

HOW TO MANAGE IT

The good news is that GSM is very treatable.

Local vaginal estrogen therapy is often the most effective option, helping to restore moisture and elasticity to the tissues with minimal systemic absorption.

For those who prefer non-hormonal routes or are unable to use hormones, vaginal moisturisers and lubricants can provide relief and improve comfort.

Consistent treatment is key, as symptoms usually return if therapy is stopped. Women can regain comfort, confidence, and control over their intimate health with the right approach.

SIGNS & SYMPTOMS OF GSM

Vulvar

Signs: Labia majora (outer labia) shrinking; loss of hair; labia minora (inner labia) thinning or fusion and pallor; pallor/red patches/pinprick rash; fissures; tightening of skin; clitoral hood retraction

Symptoms can include: Dryness, itching, irritation, burning

Vaginal

Signs: Vaginal mucosa pallor/red patches/pinprick rash; loss of moisture; loss of elasticity; loss of vaginal rugae (the natural folds or ridges that allow the vagina to stretch); pale, thin, smooth, or shiny vaginal walls; narrowed vaginal opening; shortening and tightening of the vaginal canal; loss of labial fullness; clitoral atrophy/shrinkage

Symptoms can include: Dryness (even outside of sexual activity); burning sensation; irritation or itching; loss of elasticity and thinning of the vaginal tissues; decreased vaginal lubrication with/ without sexual activity; pain or discomfort with sexual intercourse (dyspareunia); light bleeding or spotting after intercourse; changes in vaginal discharge

Urinary

Signs: Red patches/pinprick rash around the urethral area; eversion or prolapse of the urethra

Symptoms can include: Dysuria (pain or burning with urination); increased urinary frequency; urgency (a sudden, strong urge to urinate); recurrent urinary tract infections (UTIs); stress urinary incontinence (leakage with coughing, laughing, or exercise); urge urinary incontinence (leakage before reaching the toilet)

Sexual

Symptoms can include: Pain or discomfort with sexual intercourse (dyspareunia); decreased/delayed orgasm; decreased sexual desire (libido); reduced arousal and orgasmic response; secondary decrease of sexual desire; painful intercourse leading to avoidance of sexual activity

TREATMENT OPTIONS FOR GSM

NON-HORMONAL OPTIONS

These are often the first step. They can also be used in conjunction with hormonal treatments.

Vaginal moisturisers

• Used regularly (not just before intercourse) to maintain vaginal moisture.

Think of it like moisturising your face – only this time, it’s your vagina getting the glow-up!

• Typically water-based moisturisers or vaginal pessaries

• Help improve elasticity and support the natural pH balance of vaginal tissues

• Contain ingredients like sodium hyaluronate and glycerol to hydrate and soothe

• Some women also find options like coconut oil or emulsifying ointment work well for them

VAGINAL LUBRICANTS

• Used at the time of sexual activity to reduce friction, dryness, and discomfort

Available in different types:

• Water-based: Gentle and less irritating to sensitive skin. Safe with condoms DEL And sex toys. Easy to clean from sheets, clothing, and skin. May require reapplication.

• Silicone-based: Longer-lasting. Suitable for more extended activity. Condom-safe. DEL Not compatible with silicone sex toys. Can be difficult to remove from clothing, sheets, and skin.

• Oil-based: Rich texture provides long-lasting lubrication. Not compatible with latex condoms. Can stain clothes and sheets.

LIFESTYLE MEASURES

• Regular sexual activity or vaginal stimulation helps maintain vaginal health by promoting blood flow and supporting tissue integrity

• Avoid irritants such as perfumed soaps, bubble baths, scented wipes, and scented panty liners, which can disrupt the natural vaginal environment and cause irritation

HORMONAL TREATMENTS

Hormonal therapies are considered the gold standard when symptoms of GSM are moderate to severe or when non-hormonal options like moisturisers and lubricants are not effective.

Local (Vaginal) Estrogen Therapy is available in several forms:

• Vaginal pessaries, e.g., Vagifem

• Vaginal creams or gels, e.g., estriol, Blissel

• Vaginal rings, e.g., Estring

• Systemic Hormone Replacement Therapy (HRT)

OTHER OPTIONS

For women who cannot or do not wish to use hormones or when symptoms are significant.

VAGINAL LASER THERAPY

• It uses CO₂ or erbium lasers to stimulate collagen production and improve blood flow in vaginal tissues, it is claimed. 

• Available privately in some clinics.

Newer Therapies (In Development or Specialist Use)

• Vaginal oxytocin pessaries: These are being studied as a potential treatment for improving vaginal health and easing symptoms. Oxytocin may help by encouraging the growth of healthy cells in the vaginal lining, which can support moisture and repair.

• Selective estrogen receptor modulators (SERMs), such as ospemifene, help with vaginal dryness and discomfort.

WOMEN IN NURSING HOMES

Many older women in residential care could significantly benefit from vaginal estrogen. It can reduce the frequency of urinary tract infections (UTIs) and the delirium that often accompanies them, helping these women feel more comfortable, healthier, and happier.

Love Your Vulva by Laura Dowling is available in bookstores now, £19.99.