Treating Menopausal Vaginal Dryness

dried roseSex is supposed to be fun, and it’s definitely not supposed to hurt.

But one of the consequences of menopause is vaginal dryness, which for many women means painful sex.

With the loss of ovarian estrogen, vaginal walls that were once elastic, expandable, supple and sturdy can, over time, become tightened and fragile. The vaginal walls 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 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!”

Non-Hormonal Treatment

The first step for most women is a trial of non-hormonal therapy. You’ll need two things – a moisturizer and a lubricant.

Vaginal moisturizers

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.

Vaginal Lubricants

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.

Don’t be shy about using lube – slather it on him and yourself and have fun.

Vaginal Estrogen Treatment

Probably the most effective treatment for dryness is vaginal estrogen. It works by restoring and thickening the vaginal mucosa, and by increasing vaginal secretions. Vaginal estrogen comes in one of three forms –

  • Estradiol tablets (Vagifem) – A small tablet inserted into the vagina once a night for two weeks, then twice a week thereafter. The vaginal estrogen tablet is for many women the easiest and least messy option, although not all women can seem to remember to use it regularly on a twice weekly basis.
  • Estrogen creams (Estrace, its generics and Premarin) – A cream inserted into the vagina once a night for two weeks, then twice a week thereafter. Same issue as with the tablet – remembering to use it. Estrogen doses are highest for the cream when used according to the package insert, but one can adjust the dose of cream by simply using less. This allows for higher doses at the onset of treatment, with lower maintenance doses once vaginal integrity and sexual function are restored.
  • Estradiol vaginal ring (Estring) – A ring inserted once every 3 months. Systemic estrogen absorption is lowest for the Estring estrogen vaginal ring, but not all women’s vaginas are large enough to accommodate the ring at first.

Safety of Vaginal Estrogen

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 treatment 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, 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.

Oral Treatment

Ospemifine (Osphena) is an oral SERM (Selective Estrogen Receptor Modulator) that was FDA-approved in 2013 to treat menopausal vaginal dryness. In the vagina, Ospemifine 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.

In animal studies, ospemiphene has been shown to block estrogen receptors in breast tissue. While this is an intriguing, it has not yet been proven in humans or shown to translate into a lower breast cancer risk for ospemiphene users.

Ospemiphene does carry a small blood clot risk, although it is smaller than that of hormone replacement. It can also worsen hot flashes, which makes it not a good option for women having menopausal symptoms other than just dryness.

What about vaginal laser treatment?

The FDA recently approved a vaginal laser called Mona Lisa Touch for treatment for menopausal vaginal dryness. The biggest potential advantages of this approach is that no hormones are used. The downsides are the need for multiple visits to complete therapy, extremely high cost (One hospital is charging $1500 for three visit treatment, none of which is currently covered by insurers) and very limited data on efficacy and long-term safety.

My biggest concern is what the risks are when this laser becomes more widely used by clinicians outside of clinical trials. It’s being promoted aggressively, and it’s non-covered insurance status could make it a real cash cow for practices. That said, I’m intrigued by the laser as a possible alternative for women unable or unwilling to use estrogen, so stay tuned on this one.

Vaginal Dilators

If you’ve been menopausal and celibate for a long time, the size of the vagina can actually decrease, and estrogen and lubricants may not 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.

With patience and determination, I’ve had many patients who’ve re-created the vagina of their youth. But 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 and have had a very satisfactory sex life just getting down to business.

But with age, her vaginal dryness and his erectile dysfunction, the old “Wham, Bam, thank you Ma’am” may not work so well anymore. The good news is that age also brings the time to take a more leisurely approach to sex and rediscover the joy of foreplay, as well as the wide variety of intimacies beyond intercourse that couples can use to have a fulfilling and enjoyable sex life.

I often refer my patients to this reading list from SEICUS – the Sexuality Education consortium of the United States – addressing the changes to sex that come with age, and strategies for adapting to and enjoying them.

One more piece of advice

If, because of dryness, it’s been awhile since you’ve had sex, don’t start treatment and then sit and wait for the urge to hit you to start having sex again. Your libido is not going to suddenly turn back on just because your vagina is ready.

You’re just going to have to do it anyway, whether you think you want to or not. If all goes well, your body will respond – “Oh yeah – Now I remember – this is fun!”

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A modified version of this post was published on WebMD.com

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