Conditions we treat in women over 45.
Painful sex, vaginal dryness, low desire, difficulty reaching orgasm, recurrent UTIs, laxity, and changes after childbirth, surgery, or cancer treatment. Eight conditions — most patients arrive with three or four at once, having been treated for none. Each is listed below with what it's actually called, why it happens, and what can be done.
Dyspareunia
Recurrent UTI
GSM
Laxity
HSDD
Postpartum
Anorgasmia
Post-cancer
01
Pain with intercourse
Dyspareunia · Vestibulodynia · Vaginal stenosis · Vaginismus
Burning, tearing, stinging, or a deep ache — during penetration, throughout, or for hours afterward. For many women it began so gradually that they adjusted around it long before they ever named it, declining more often, using more lubricant, bracing for it.
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Pain is the symptom women delay raising longest, and the one most likely to be met with a suggestion to relax or have a glass of wine. It is a physical finding with physical causes, and it is measurable on examination.
WHAT'S HAPPENING UNDERNEATH
As estradiol falls, the vaginal wall loses cell layers, collagen, and elasticity. Thinner tissue tears more easily and lubricates less. Where pain has persisted for months or years, the pelvic floor often adds a protective guarding response — muscles that tighten in anticipation — which becomes a second, compounding source of pain on top of the first.
WHAT WE DO ABOUT IT
Examination and hormone assessment first, to establish whether the driver is tissue, muscular, microbiome, or a combination. Treatment typically combines regenerative therapy to rebuild tissue quality with local hormonal support where appropriate.
02
Dryness & tissue change
Genitourinary syndrome of menopause (GSM) · Vulvovaginal atrophy · Lichen sclerosus screening
Affects an estimated 50–70% of menopausal women
Persistent dryness, thinning, irritation, itching, a raw or papery feeling, occasional light bleeding after sex. Often the first change women notice, and almost always the one dismissed fastest.
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Genitourinary syndrome of menopause is chronic and progressive — meaning that unlike hot flashes, it does not improve with time. Left untreated it continues. It remains underdiagnosed and undertreated worldwide, largely because women are told, and come to believe, that the change is simply part of aging.
WHAT'S HAPPENING UNDERNEATH
Estrogen maintains the thickness, blood supply, and glycogen content of vaginal tissue. As it declines, the epithelium thins, natural lubrication drops, pH rises, and the tissue becomes more fragile and more reactive. A moisturizer addresses the surface for a few hours. It does not change any of the four things above.
WHAT WE DO ABOUT IT
Examination and hormone assessment first, to establish whether the driver is tissue, muscular, microbiome, or a combination. Treatment typically combines regenerative therapy to rebuild tissue quality with local hormonal support where appropriate.
03
Desire that disappeared / Low Libido
Hypoactive sexual desire disorder (HSDD) · Androgen insufficiency · Arousal disorder
Roughly 16 million American women over 50 report low sexual desire
Loss of interest, loss of arousal, or a disconnect where desire used to arrive on its own and now doesn't arrive at all. Particularly telling when it appeared suddenly, after surgery, or alongside other menopausal changes rather than gradually over years of ordinary life.
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Low desire is routinely treated as psychological by default — a relationship issue, a stress issue, a mood issue. Sometimes it is. Often it is endocrine, and nobody measured.
WHAT'S HAPPENING UNDERNEATH
Desire depends on testosterone, estradiol, DHEA, and dopamine signaling. Women produce testosterone throughout life and levels decline with age — and fall sharply and immediately after removal of the ovaries. Standard panels frequently don't test free testosterone or DHEA-S at all, which means a treatable cause goes unlooked-for rather than ruled out.
WHAT WE DO ABOUT IT
​Measure what standard panels skip: free and total testosterone, DHEA-S, estradiol, SHBG, thyroid, and prolactin. Where levels support it, testosterone therapy for low desire after menopause is supported by multiple randomized controlled trials — and remains rarely offered to women. Where the driver is tissue or arousal rather than desire itself, we treat that instead.
04
Sensation & orgasm
Anorgasmia · Delayed orgasm · Reduced genital blood flow · Reduced sensation
Reduced sensitivity, orgasm that takes far longer than it used to, or orgasm that still happens but has become faint. Frequently reported alongside dryness, and frequently assumed to be permanent.
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This is among the least-discussed changes of all — partly because it's difficult to raise, partly because most women assume there is no physiological explanation to raise.
WHAT'S HAPPENING UNDERNEATH
Orgasmic function depends on pelvic blood flow, nerve sensitivity, and tissue health — all three of which are affected by estrogen decline. Reduced vascularity means less engorgement and less sensation. Thinner tissue transmits less. These are circulatory and structural changes, which is precisely why therapies aimed at blood flow and tissue quality are relevant here.
WHAT WE DO ABOUT IT
Assessment of tissue health and hormone status, then therapies directed at vascularity and tissue regeneration rather than at desire.
05
Urinary symptoms & recurrent UTIs
Recurrent urinary tract infection · Urgency · Frequency · Stress incontinence · Urogenital atrophy
Urgency, frequency, waking at night, leaking when you cough or lift, burning without infection, and infections that return within weeks of finishing treatment.
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These are almost always managed as a urological problem, separately from anything gynecological. That separation is the reason so many women cycle through antibiotics for years without the underlying driver ever being addressed.
WHAT'S HAPPENING UNDERNEATH
The urethra and the trigone of the bladder carry the same estrogen receptors as vaginal tissue. They atrophy on the same timeline, from the same cause. Meanwhile the vaginal microbiome shifts away from Lactobacillus dominance, pH rises, and the environment that used to suppress uropathogens no longer does. The infection is the visible event; the microbiome and tissue change is what allowed it.
WHAT WE DO ABOUT IT
Vaginal microbiome analysis to identify what has actually shifted, then restoration alongside tissue treatment. Treating the urinary symptoms and the dryness as one condition is usually the difference between fewer infections and the same cycle continuing.
06
Laxity & loss of structural tone
Vaginal laxity · Loss of tissue volume · Reduced structural elasticity
A looser, less toned vaginal canal, reduced friction and sensation during intercourse, and a sense that the tissue simply doesn't hold the way it once did. One of the most common changes after childbirth or with age, and one of the least raised — usually because women expect it to be treated as a cosmetic complaint.
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It isn't cosmetic. Tissue laxity has a physical cause — reduced collagen density, thinner vaginal wall tissue, loss of structural volume — in the same category as skin laxity or volume loss anywhere else in the body. It happens to be far less openly discussed.
WHAT'S HAPPENING UNDERNEATH
Vaginal tissue tone depends on collagen density, tissue volume, and structural elasticity. All three decline with age, and all three are frequently disrupted by vaginal childbirth. This is a structural change rather than a hormonal one alone, which is why it often persists even when hormone therapy has resolved dryness.
WHAT WE DO ABOUT IT
Where laxity is the primary concern and candidacy is confirmed, Dr. Merhi may recommend adipose-derived PRP — a small volume of your own fat, harvested under local anesthesia and combined with platelet-rich plasma, then injected into the vaginal wall to restore structural volume and stimulate tissue regeneration. Candidacy is assessed case by case; this is not appropriate for every patient.
PLEASE READ - SAFETY
Fat grafting into vaginal tissue is a surgical procedure with real risks, not a spa treatment. A published case report documents a severe fat embolism following autologous fat grafting at this injection site — a rare but serious complication. We state it here rather than only at consent. Risks, benefits, alternatives, and limitations are reviewed in full during consultation, and Dr. Merhi will decline the procedure where he does not consider it appropriate for you.
07
After childbirth
Postpartum tissue change · Perineal scarring · Postpartum dyspareunia · Pelvic floor dysfunction
Tissue stretching, scarring at a tear or episiotomy site, reduced tone, pain at a specific point rather than throughout, and changes that were noted at the six-week visit and never revisited.
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Postpartum care in the United States effectively ends at one appointment. Women who are decades past childbirth frequently trace a change back to it and have never been evaluated for it since — often because they assumed the window for doing something had closed.
WHAT'S HAPPENING UNDERNEATH
Vaginal delivery can stretch tissue beyond its recoil, and scar tissue at a tear or episiotomy site is structurally different from the tissue around it — less elastic, sometimes tethered, often the source of a sharp, localized pain that feels different from generalized soreness. Breastfeeding suppresses estrogen, which adds atrophy on top of that during the months when it's most likely to be attributed to exhaustion.
WHAT WE DO ABOUT IT
Examination to distinguish scar-related pain from tissue atrophy from pelvic floor guarding — three different problems that feel similar and need different treatment. There is no expiry on this: we treat women who gave birth last year and women who gave birth thirty years ago.
08
After surgery or cancer therapy
Surgical menopause · Post-hysterectomy · Post-oophorectomy · Treatment-induced atrophy
Changes following hysterectomy, removal of the ovaries, chemotherapy, or years on an aromatase inhibitor. Frequently abrupt rather than gradual — surgical menopause arrives in a single day rather than over several years, with no adjustment period.
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Women with a history of hormone-receptor-positive breast cancer are advised against systemic hormone therapy and are then offered little beyond a moisturizer — despite having higher rates of genitourinary symptoms than women who never had cancer. This is the group most likely to be told there is nothing left to try.
WHAT'S HAPPENING UNDERNEATH
Aromatase inhibitors work by suppressing estrogen production near-completely, which is exactly why they're effective against hormone-receptor-positive disease — and exactly why the genitourinary effects are more severe than in natural menopause. Removal of the ovaries produces the same effect surgically and instantly. The tissue change is the same; the speed and depth are greater.
WHAT WE DO ABOUT IT
The in-clinic therapies we use for this group act locally and without systemic hormones — PRP is prepared from your own blood; ozone and photobiomodulation are delivered to the tissue directly. We ask for your oncologist's contact details at the first visit and coordinate as a matter of routine. We will not prescribe against their guidance, and we will tell you plainly if we don't believe we can help.