Women's-health experts estimate that half of the 55 million women over age 50 in this country experience discomfort from vulvar and vaginal dryness and atrophy, but only a quarter of them ever report their symptoms to a medical professional. And because even baby boomers, that most famously sexually liberated generation, can be embarrassed to discuss these intimate problems, shared experience is often not shared among peers.
"People talk about hot flashes, emotional lability, and insomnia," said Susan Kellogg Spadt, a specialist in pelvic and sexual health. "But it's funny, they rarely say, 'Are you burning like fire when you're entered?' It's the part that gets left out."
Perhaps it's the stigma about aging in American society, several women's-health experts said, but mothers who had no trouble recounting epic stories about episiotomies - the surgical incisions during labor - are more reticent about those same parts 30 or so years on.
While the physiology of menopause is undoubtedly complex, Kellogg Spadt said, the underlying issue is fairly simple.
Just as the face and neck wrinkle and lose moisture, she said, so do genitalia: "It's aging skin."
A variety of remedies, from regular sexual activity to prescription medications, can keep the tissues healthier. Too often, however, women are poorly informed about what to expect and unaware of the measures they can take.
In her practice, the Center for Pelvic Medicine in Bryn Mawr, one of the most common stories Kellogg Spadt hears is from women who, thinking they have a yeast infection, buy an over-the-counter medication that makes the pain worse.
"It happens all the time," she said. "And what's tragic," she added, is that even after patients go to see their health-care provider, the right diagnosis may still not be made. "These women begin to question themselves. They lose faith in their own voice."
Given the current wealth of knowledge about menopause, why are so many women taken by surprise by vulvar and vaginal pain? And why are health professionals still missing the obvious?
"It's not a conspiracy," said Ann L. Steiner, associate clinical professor of obstetrics and gynecology at the Hospital of the University of Pennsylvania.
"I have handouts that I give to anyone with any sign at all of symptoms. But women are less likely to talk about sex than they are about a headache or arthritis."
As for the failure to properly diagnose, Steiner said, "There's been a noticeable lack of education in our residencies about menopause."
To help make sure that Penn's doctors are properly trained to care for women at all stages of life, she said, in July the university began requiring all residents to do a rotation in the hospital's menopause clinic, where she serves as director.
"The lifespan is 81-plus years for women and the average age of menopause is 51," Steiner said. Considering how large a portion of life is involved, "it's important to put it on the radar for doctors, nurses, and nurse practitioners."
It is also important, she added, to understand that menopause is not an illness: "Not everybody gets symptoms."
There is good data, Steiner said, showing that most women look at menopause not as a medical condition, but as another, and usually better, stage of their lives. "They think they feel better in their 50s and 60s than they did earlier in their lives. These women also probably have better self-esteem and body image than adolescent girls."
But the pain, for those who experience it, can be dramatic.
"Women are sometimes stunned by how much hot flashes can change their lives. The exhaustion, they don't sleep at night, the overwhelming discomfort," Steiner said.
In addition to making intercourse painful, changes in the vulva and vagina can lead to urinary and bladder problems.
"It's not a woman's fault, but the adage that if you don't use it you lose it in this case is true," Kellogg Spadt said - one of the downsides, she noted, of "going into early sexual retirement."
Sexual activity creates more blood flow, which tends to keep the tissues "happier."
Lubricants make sex more comfortable, but creams and lotions are required to moisturize delicate tissues. If more help is needed, at least four prescription medications are available to treat vaginal atrophy with low-dose topical estrogen.
A vaginal ring (akin to the now virtually extinct contraceptive diaphragm) releases the hormone gradually and is replaced every three months. There also are estrogen creams, and a tiny tablet suppository, that are used two or three times a week.
"Vaginal changes at menopause are not the only thing that can cause uncomfortable intercourse," said Margery Gass, executive director of the North American Menopause Society, a professional association based in Cleveland. "A fair number of women experience vulvar or vestibular pain [the vestibule is the anatomy at the entrance to the vagina] . . . that is frequently being missed by clinicians who think women only have vaginal atrophy. Women are being misled, told to just use lubricants or have sex more often."
And hip, back, or knee pain may throw off body mechanics and create spasms in the pelvic floor muscles. This, Steiner said, can be relieved with physical therapy. Vaginal tightening may be helped by the use of dilators.
"After menopause, there is a new normal," Kellogg Spadt said. "But sex should never, never be painful."
In an effort to encourage more candid conversations, the North American Menopause Society and the International Society for the Study of Women's Sexual Health came up with a new term for the constellation of disturbances "down there."
After two days of debate at a meeting last summer, members of the two societies agreed upon "Genitourinary Syndrome of Menopause," or GSM.
" GSM captures the concept that it's not just the vagina, but also the lower urinary tract that can be involved," Gass said. " Syndrome conveys the idea that there are multiple symptoms and not everyone has the same ones."
Furthermore, "GSM is something that can be said more easily in public than vagina and penis."
If the revised terminology works, Gass said, perhaps fewer women will suffer in silence.
"I view this as part of my fitness discussion when women come in to see me at midlife," she said. She understands, though, that clinicians are under time constraints during office hours and may not get around to talking about every concern.
"We all need to be more proactive about this," she said. "It does sneak up on women."