What Really Happens To The Vulva In Menopause
LABIAL AND CLITORAL ATROPHY EXPLAINED
A few weeks ago, a video from my friend and colleague Dr. Rachel Rubin went mega viral. In it, she explained that the labia can change dramatically after menopause.
The reaction was immediate and intense. Shock. Disbelief. Grief. And the same question repeated millions of times:
“Why didn’t anyone tell me this could happen.”
As a menopause specialist, I was not surprised by the content of the video. What shocked me was how many women felt blindsided. How many had never been told. How many felt scared or ashamed when they noticed changes in their own anatomy.
Because while your labia do not disappear after menopause, they absolutely can change in predictable, physiological, and often distressing ways.
But here is the part almost no one is talking about.
The part that affects pleasure, orgasm, and sexual identity.
The part women whisper about in my DMs but are afraid to ask out loud.
It is not just the labia that change.
The clitoris changes too.
And that changes everything.
These are not cosmetic issues. These are symptoms of genitourinary syndrome of menopause (GSM), a medical condition driven by estrogen deficiency that affects the vulva, vagina, clitoris, urethra, and bladder. Women deserve to understand what is happening to their bodies.
What Happens to the Labia After Menopause
The labial changes that occur after menopause are not sudden or dramatic overnight shifts. They are gradual, cumulative, and layered, reflecting years of estrogen decline and the downstream effects that deficiency has on skin, connective tissue, nerves, and vascular supply. Most women never learn this in advance, so when they start noticing differences in the mirror, or changes in how clothing feels, or new sensations during intimacy, they feel blindsided.
These changes are common, physiological, and rooted in hormone loss. And when we understand what is happening on a tissue level, everything finally makes sense.
Thinning and Atrophy
When estrogen drops, the labia majora and minora lose the structural support that kept them thick, soft, and elastic during the reproductive years. Histological studies show:
• thinning of the epithelial layer
• reduced fibroblast activity
• decreased collagen and elastin
• diminished vascularity
• flattening of the dermal ridges
(Factors, 1962; Galęba et al., 2015; Gass & Portman, 2014a; Farage et al., 2019; Phillips & Bachmann, 2015)
This is the same process that affects the vaginal walls and urethra, but it is more visible externally, which is why so many women notice it first on their labia.
Clinically, women describe:
• feeling “deflated”
• tissue that seems papery or fragile
• more irritation from clothing
• discomfort with wiping, walking, or riding a bike
The skin simply does not have the same thickness or resilience to friction, moisture changes, or microtrauma.
Loss of Volume and Moisture
Another major change is lipoatrophy of the labia majora. The fat pads that once gave the vulva fullness and cushioning begin to shrink because adipocytes respond directly to estrogen signaling. As volume declines, the labia:
• appear flatter rather than rounded
• lose their protective padding
• show more wrinkling or sagging
• may expose the labia minora more prominently
Pigmentation can also fade because melanocyte activity decreases. Hair follicles miniaturize, so the pubic hair pattern becomes sparser, softer, and lighter. The overall look becomes paler, smoother, and less defined.
Reduced sebum and sweat gland activity contribute to dryness and increased vulnerability to chafing. Many women describe a sensation of “tightness” or “pulling,” even before penetrative sex becomes painful.
These changes are physical, structural, and hormonally driven. They are not caused by hygiene, aging alone, or anything a woman has done wrong.
Structural Changes
The labia minora are especially sensitive to estrogen changes. As the tissue thins, several structural shifts can occur:
• the labia minora may flatten
• the edges can smooth out
• they may adhere to nearby tissue, especially near the clitoral hood
• fissures and microtears may appear after sex or exercise
The labia majora can retract inward because of both lipoatrophy and the loss of tensile strength in the supporting fascia. This can make the vulvar vestibule more exposed, more sensitive, and more prone to irritation from clothing, pads, sex, or even sitting.
These structural changes are often the first sign of GSM, even before vaginal dryness is recognized.
Aging of Surrounding Structures
Sarcopenia, generalized fat loss, and changes in pelvic floor tone can amplify vulvar changes. When muscle mass decreases, the external genital tissues lose some of their natural support and fullness. Combined with estrogen deficiency, this can make the vulva look dramatically different over time:
• more recessed or “sunken” appearance
• changes in symmetry
• increased prominence of the perineal body
• visible shifting of the labial contour
Women frequently come to my office asking if something is wrong or if their anatomy is “collapsing.” Nothing is collapsing. The tissues simply need the hormones they once depended on.
And then there is the most overlooked change of all.
It is not the labia that matter most.
It is the clitoris.
This is the change that affects pleasure, orgasm, sexual identity, and self confidence. It is the change almost no one warns women about. And it is the change that is most directly restored with treatment.
The Change No One Warns You About
Clitoral Atrophy and Orgasm Dysfunction
During my recent unPAUSED interview with Dr. Corinne Menn, she said something so simple and so profound that it stopped me in my tracks.
The clitoris is estrogen dependent tissue.
That single sentence explains decades of confusion, shame, and misdiagnosis for millions of women. Because when estrogen declines, the clitoris does not remain untouched. It changes in predictable, measurable, histological ways. And these changes directly affect sexual pleasure, arousal, and orgasm.
Most women have never once been told this.
Most clinicians have never been trained in it.
And that silence has allowed countless women to believe that losing orgasm is a personal failing rather than a medical condition.
What Actually Happens to the Clitoris
The clitoris is not just the external glans. It is an extensive internal organ made of erectile tissue, nerves, blood vessels, and fascia that extends several centimeters deep into the pelvis. And like the vagina and labia, it requires estrogen for:
• vascular engorgement
• lubrication from surrounding glands
• epithelial health
• nerve responsiveness
• tissue elasticity
When estrogen declines, the clitoris undergoes changes similar to those we see elsewhere in the urogenital tract.
These include:
Shrinking of the clitoral glans
With less estrogen, the glans becomes smaller, flatter, and less firm. It may appear less prominent or even “hidden.” This is a documented physical change, not a cosmetic one.
Tightening or burial of the clitoral hood
As the hood loses elasticity, it can begin to contract or adhere, partially burying the clitoral glans beneath it. Women describe needing more stimulation to feel anything or feeling like the area is less accessible than before.
Reduced blood flow
Estrogen promotes nitric oxide production and vasodilation. Without it, the erectile bodies of the clitoris do not engorge the same way. Less blood flow means less swelling, less sensitivity, and less pleasure.
Decreased sensitivity and muted nerve signaling
Histological studies show reduced nerve density and impaired neural responsiveness in low estrogen states. This can feel like numbness, dullness, or needing far more stimulation to reach the same sensation.
Delayed orgasms, weaker orgasms, or absence of orgasm entirely
Many women reach the point where they can still get aroused mentally, but their body cannot follow through. Orgasms become slower, softer, or disappear altogether.
Women Think It Is Psychological. It Is Not.
I hear this every single day:
“I thought it was just aging.”
“I thought my libido vanished.”
“I thought it was stress.”
“I thought something was wrong with me.”
“I thought I was broken.”
But the truth is far simpler and far kinder.
This is not about desire.
It is about physiology.
The clitoris is a vascular, hormonal, neural organ. It needs estrogen to do what it was built to do. When estrogen declines:
• blood flow decreases
• nerves fire more slowly
• tissue becomes less responsive
• arousal takes longer
• orgasm changes shape
This is genitourinary syndrome of menopause.
This is medical.
And it is treatable.
Why This Matters So Much
Sexual pleasure is not a luxury. It is not vanity. It is a vital part of sexual health, relational health, pelvic health, and overall wellbeing. When the clitoris changes, women can feel a loss they cannot name. Many experience grief, frustration, or a sense of disconnection from their bodies.
They begin to feel:
• undesirable
• desexualized
• ashamed
• “not themselves anymore”
But none of this is their fault.
These changes are rooted in hormone loss, not personal failure. And the most important message is this:
Clitoral atrophy is reversible when treated properly.
Just like the labia, clitoral tissue responds robustly to local estrogen therapy. Blood flow improves, nerve response improves, hood adhesions soften, and orgasms often return with surprising strength.
Women deserve to know that this is possible. They deserve clinicians who understand how to treat it. And they deserve a sexual future that does not end just because their ovaries retired.
What Causes These Changes
Estrogen maintains the entire urogenital system. It is responsible for:
• tissue thickness
• elasticity
• blood flow
• lubrication
• pH balance
• epithelial repair
• nerve responsiveness
When estrogen declines, the vulvar and clitoral tissue becomes thin, fragile, dry, inflamed, and less sensitive. This has been confirmed through histological and gene expression studies showing reduced collagen, elastin, hyaluronic acid, and wound healing capacity (Farage et al., 2019).
These changes are not subtle. They are measurable and well documented. Yet women are rarely warned.
What Actually Reverses These Changes
Over the counter lubricants and moisturizers help with friction. They do not rebuild tissue. They do not restore clitoral sensitivity. They do not fix the problem.
Only the following therapies treat the root cause:
Prescription vaginal estrogen
Prescription vaginal DHEA (prasterone)
These are the only interventions proven to:
• increase epithelial thickness
• restore collagen and elastin
• improve blood flow
• increase lubrication
• improve urinary symptoms
• enhance sexual function
• restore clitoral responsiveness
And they are safe for the vast majority of women, including many survivors, as discussed at length in my conversations with Dr. Corinne Menn and Dr. Lauren Streicher.
The 2025 AUA Guidelines: A Turning Point
In a landmark moment, the American Urological Association formally recognized GSM as a critical health issue and strongly endorsed vaginal estrogen as a safe and essential treatment.
This matters because GSM does not only show up in gynecology offices.
It shows up in urology, dermatology, rheumatology, primary care, and mental health.
The AUA also emphasized something I have been shouting from the rooftop for years:
GSM is underdiagnosed.
GSM is undertreated.
GSM is progressive.
And GSM affects quality of life, relationships, sleep, bladder health, bowel health, and sexual identity.
Women deserve better.
Why This Matters
I have had women sob in my office because no one told them what to expect. They were frightened by the changes in their anatomy. They blamed themselves for painful sex or weak orgasms. They thought they were broken.
They were never broken. They were never alone. They were never supposed to suffer.
What Dr. Rubin’s viral moment did was rip the curtain back. It created visibility for the changes women were already experiencing.
It told women,
“You are not imagining this. And you are not powerless.”
You Deserve Answers
If you have noticed changes in your labia or clitoris after menopause, you are not alone. These changes are real, treatable, and reversible.
You deserve clinicians who understand GSM.
You deserve accurate information.
You deserve options.
You deserve relief.
To find a trained menopause clinician, download our free Menopause Empowerment Guide.
To go deeper, watch these full unPAUSED episodes: (put titles and links once available)
And subscribe on YouTube or Apple Podcasts to stay informed.
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References
Factors, N. (1962). VII. Predisposing Factors. Acta Radiologica, 58(S217), 24–29.
Galęba, A., Bajurna, B., & Marcinkowski, J. (2015). The Role of Cosmetic Gynecology Treatments in Women in Perimenopausal Period. Open Journal of Nursing, 5, 153–157.
Gass, M., & Portman, D. (2014a). Genitourinary syndrome of menopause. Menopause, 21(10), 1063–1068.
Gass, M., & Portman, D. (2014b). Genitourinary syndrome of menopause. Climacteric, 17(5), 557–563.
Farage, M., Sharma, K., Wang, Y., et al. (2019). Histological and Gene Expression Analysis of Menopause Effects. Journal of Clinical Medicine Research, 11(10), 745–759.
Phillips, N., & Bachmann, G. (2015). Vaginal health prescription. Menopause, 22(2), 127–128.