"My vagina is as dry as the Sahara desert!" was written in all block letters by a recent patient on the top of her paperwork as her chief complaint. I chuckled as I entered the room, but luckily was able to offer her a variety of treatment options.
Most women know that menopause often causes women to experience their "own person summers" with hot flashes and night sweats, but another common symptom is vaginal dryness, which can mean painful and less enjoyable sex.
The vaginal walls contain an abundance of estrogen receptors. When estrogen level plummet during menopause vaginal walls that were once elastic, expandable, supple, and sturdy can, over time, become tightened and fragile. The skin can become as thin as tissue paper, unable to withstand the manipulation that occurs with sexual activity, and can tear and even bleed with intercourse.
“Use it or lose it”
When sex becomes painful, the natural response is to begin to avoid intercourse. But without continued sexual activity (masturbation counts, too), the vagina becomes even smaller and tighter, making a bad problem even worse. Add in a partner with erectile dysfunction (common in older men) and it’s not unusual for a woman to present to me not having had sex in a year or more, wondering if there’s anything that can be done to get back the sex life she and her partner once enjoyed.
Fortunately, the answer is almost always a resounding “Yes!”
The first step for most women is a trial of non-hormonal therapy. You’ll need two things – a moisturizer and a lubricant.
Think of how you take care of your skin – you moisturize it daily, right? Well, the menopausal vagina needs the same thing. It doesn’t have to be every day, but it has to be regular and consistent.
I don’t promote products, but I do tell my patients about Replens - it’s been studied and shown to be as effective as vaginal estrogen in restoring the premenopausal vaginal mucosa. Revaree is another option that is make of hyaluronic acid (yes the same stuff we use on our face to treat wrinkles) that many of my patients have found super helpful.
Have fun trying out brands, but avoid flavored and scented products if you tend to be sensitive to them. If you need STD protection, stick to water-based lubricants that will not degrade condoms. Uberlube is a brand that is silicone based and many women find it not to be as sticky as other brands. If you want to try something more natural, coconut oil (yes the same stuff you cook with) can be used for both a moisturizer and lubricant (but again, because it’s oil-based, it’s not for use with condoms).
Vaginal Hormonal Treatment
Vaginal estrogen therapy
If low estrogen causes vaginal dryness, then it's probably not surprising that the most effective treatment for dryness is adding estrogen back to the vagina.
Vaginal estrogen works by thickening the vaginal walls, improving blood flow to the vaginal area and by increasing natural vaginal secretions. It comes in many options–Estradiol tablets (Vagifem), Estradiol vaginal suppositories (Imvexxy), and Estrogen vaginal creams (Estrace and Premarin), and the estradiol vaginal ring (Estring). Estrogen doses are lowest for the ring and highest for the cream, but you can adjust the dose by simply using less cream. This allows for higher doses at the beginning of treatment, with lower maintenance doses once vaginal integrity and sexual function are restored.
Safety of vaginal estrogens
Women hear the word “estrogen” and immediately become concerned – not surprising given the findings of the Women’s Health Initiate in 2002 that hormone replacement is associated with a small increase in breast cancer risks. However, estrogen exposure from use of vaginal estrogen is much lower than that with hormone replacement, and blood levels of estrogen remain within the menopausal range. These small amounts of estrogen do not carry the same risks of blood clots as does hormone replacement, and there is no increase in uterine cancer rates with vaginal estrogen use for up to 5 years. Despite these differences, vaginal estrogens carry the same FDA warnings as systemic hormone replacement, and menopause experts have petitioned the FDA to correct the vaginal estrogen package insert.
All of that said, we do not have long-term data on breast cancer risks from vaginal estrogen, and women at high risk for breast cancer or with a history of breast cancer generally want to avoid even the small amounts in vaginal estrogen, especially if they are taking aromatase inhibitors to lower breast cancer risks. If non-hormonal treatments are ineffective, some high-risk women may be willing to use a short course of estrogen to restore vaginal integrity and sexual function, followed by over-the-counter moisturizers for long-term maintenance therapy.
What about estriol cream?
Estriol is a weak estrogen that is effective for vaginal dryness, often made at compounding pharmacies, but is not FDA-approved. If you’re avoiding the FDA-approved products because you don’t want to take estrogen, then take estriol off the list as well. It’s just another estrogen.
Vaginal DHEA therapy
Intrarosa is a prescription DHEA vaginal suppository. DHEA is hormone secreted by your adrenal gland that, once absorbed by the vaginal tissue, gets turned into estrogen inside the calls. This is great option for women wanting to avoid estrogen products completely.
Ospemifine (Osphena) is an oral SERM (Selective Estrogen Receptor Modulator) that acts like estrogen, restoring vaginal moisture and the integrity of the vaginal mucosa. Ospemiphene can stimulate growth of the uterine lining, although in postmenopausal women, this effect is minimal. It does carry a small blood clot risk, although it is less than that of hormone replacement. One side effect of Ospemiphene is hot flashes.
If you’ve been menopausal and celibate for a long time, estrogen and lubricants may not be enough to restore normal sexual activity. In that case, your doctor can prescribe a set of vaginal dilators – soft plastic rods that come in graduated sizes from 3 mm to 10 mm in diameter, allowing for a gradual increase in vaginal capacity.
Not every patient I’ve offered dilators feels up to the task. In that case, they confine their sexual activities to non-penetrative sex, which for many women, is where the fun is anyway.
Which brings me to…
The Forgotten Art of Foreplay
Over years of being together, what with children and a busy life, some couples may have gotten out of the habit of foreplay, but have had a very satisfactory sex life just getting down to business. But now, with her vaginal dryness and his erectile dysfunction this may not work so well. The good news is that there is now time to rediscover the joy of foreplay, as well as the wide variety of intimacies other than intercourse.
One more piece of advice about getting started again with sex. If, because of dryness, it’s been awhile since you’ve had sex, don’t start treatment and expect everything to get back to normal immediately. It usually takes 6-8 weeks for the vaginal tissue to return to the premenopausal state.
There are many symptoms of menopause that can be challenging to treat, but luckily vaginal dryness is not usually one of them. Currently we have many safe and effective treatment for this common problem. If you are struggling with vaginal dryness don't be embarrassed. Tell your provider about your "Sahara vagina" – they want to help!