I would still consider a hormonal issue based on the long term use of birth control pills. Sometimes it can take years for the tissue to become damaged from the lack of hormones.

If you haven’t tried a topical hormone cream massaged into the area daily, or even twice daily, I would start there.

I often try to switch my patients to a different method, maybe an IUD, and then use topical estrogen or estrogen and testosterone to the area.

It can take months for the area to respond and heal, but often my patients will find some improvement after a month.