Vaginal Dryness Treatment

Vaginal dryness is a delicate topic for many women during perimenopause, menopause and beyond. From the bathroom to the bedroom, it can cause physical and emotional distress that's difficult to explain to your provider, partner or even your best friend. Since vaginal dryness is directly linked to declining estrogen levels, women will experience it for the rest of their postmenopausal life. The good news is that, with Khloe, you have the support and resources to help you through this midlife change.

As estrogen levels in the body decrease, the tissue inside the vagina produces less natural lubricant, and the lining becomes thin and fragile. This lack of lubrication paired with a delicate lining can cause irritation, itching, and burning. Vaginal dryness can lead to intimacy and relationship issues for women. Seventy-five percent of women reported it negatively affected their sex life, and 45 percent said they'd experienced discomfort while having sex. This natural biological change doesn't have to mean the end of your sensuality. You have options and with the right treatment, enjoying sex can be possible again.

Since sex talk isn't exactly small talk and knowledge about treatments can be sparse, many women suffer in silence. Here at Khloe, we believe it's time to start the conversation and explore your options. For vaginal dryness, a provider can prescribe, if appropriate, a cream that's applied locally to the vagina. This application has been shown to restore the vaginal lining which leads to increased lubrication. We also carry an over-the-counter, all-natural, water-based lubricant and vaginal moisturizer. It's vital to educate yourself about each option, including the risks and benefits of prescription products. We'll always guide your choice with the support and resources you need along the way.

Getting the proper amount of high-quality sleep is necessary to function at your best. High quality sleep is uninterrupted and it slips smoothly through each sleep cycle (discussed below). Your body and mind both suffer if either your quality or duration of sleep is insufficient. Prolonged periods without proper sleep can compromise nearly every aspect of your health.

The American Academy of Sleep Medicine and the Sleep Research Society recommend that adults sleep 7 or more hours per night on a regular basis for optimal health. Despite this advice, the CDC estimates that about 35% of adults sleep fewer than 7 hours per night. Sleeping fewer than 7 hours is associated with (either causing or caused by) many diseases, including:

Obesity
Diabetes
Hypertension (High Blood Pressure)
Heart disease
Stroke
Depression
Increased risk of death
Poor immune function
Increased pain
Higher risk of accidents

average age of menopause in the United States is 51 years old but it is possible to experience it at a much earlier age. About 1% of women will experience menopause before age 40 (premature menopause) and 5% will experience it before age 45.

Perimenopause is defined as the transition from having regular menstrual cycles to the complete cessation of menstrual cycles. It usually begins when a woman who previously had cycles that were regular with a predictable length begins having irregular periods before eventually having no periods at all. Women enter perimenopause on average about 4 years before they stop having periods altogether.  

It is in this early period just before menopause when symptoms like vaginal dryness can start to appear. The most common symptom during perimenopause and menopause is hot flashes/flushes, which is estimated to occur in over 75% of women during midlife, but vaginal dryness is also remarkably common.

Subtle changes occur throughout the reproductive system, including the vagina-and unlike hot flashes and other general menopausal symptoms, vaginal changes do not improve with time, and often worsen with each passing year. The decreasing levels of estrogen cause the vaginal tissue and the vulvar skin (outer lips of the vagina) of the genitals to become atrophic-meaning the skin begins to lose its normal, thick structure.

The vagina also becomes more susceptible to yeast and other infections. The once healthy balance of organisms that was supported by a slightly acid, vaginal environment is altered in the less acidic, estrogen-deprived vagina of menopausal women.The term used to describe all the changes that occur in the vagina and vulva is vulvovaginal atrophy (VVA).

Other symptoms related to the loss of estrogen in the genital region include urinary tract symptoms (e.g., frequent urination, a sense of urgency, loss of urine with stress, need to urinate at night) since the skin in the area of the urethra (the tube that carries urine) is affected by the loss of estrogen.

Taken together, symptoms of menopause involving the vaginal tissue and the urinary tract are called the Genitourinary Syndrome of Menopause (GSM). You will often see vulvovaginal atrophy (VVA) and Genitourinary Syndrome of Menopause (GSM) clumped together as VVA/GSM. GSM includes all the symptoms that may occur and respond to therapy as described below.

Before perimenopause or menopause, the vagina is usually moist with skin that is pink from abundant blood vessels. There are multiple folds of extra skin and mucous secreting sebaceous glands that can produce moisture quickly during sexual excitement.

When estrogen is lost the skin becomes thin, pale, and dry. The vagina narrows and shortens. The opening to the vagina, called the introitus, can narrow, as well-especially when penetrative sex is not practiced.

The vaginal skin can become so thin that small breaks in the blood vessels (now far fewer in number) can occur, the once abundant folds of extra skin disappear, and the vagina loses much of its capacity to expand when needed.

The sebaceous glands may remain but they do not function well. The natural lubrication women experience with stimulation is both lessened and delayed.

REVIVE study,

85% of partnered women had some loss of intimacy
59% indicated symptoms affected their enjoyment of sex
47% of women with partners said their symptoms interfered with their relationship

Vaginal dryness and the other vaginal changes associated with menopause are not minor inconveniences for many women. They can be life-altering.

Non-hormonal Remedies (Adapted from NAMS recommendation)  

Vaginal lubricants are an excellent first choice in dealing with mild vaginal dryness during sexual activity. Their regular use may reduce discomfort with sexual activity. The choice of personal lubricant is often quite personal, but it is generally recommended that patients use a water-based lubricant to relieve the symptoms of vaginal dryness. Oil-based lubricants may lead to increased infections and discomfort, and alcohol containing lubricants can burn.  

Vaginal moisturizers help prevent itching and general discomfort by maintaining vaginal moisture. They are typically applied internally a few times/week at night to avoid leakage. Regular sexual stimulation increases vaginal blood flow and results in increased secretions. The good news is that any sexual stimulation will be beneficial. It does not require a partner. However, as you will read below, combining stimulation with vaginal penetration helps to maintain the width of both the vagina and the introitus (the opening to the vagina). Again, a partner is not an absolute necessity to complete this exercise.  

Vaginal dilators are helpful if there have already been some changes in the width, length, or flexibility of the vagina and the opening to the vagina. Used prudently and with guidance from a healthcare professional, dilators can be a safe and effective aid in regaining lost comfort and function.

Pelvic floor exercises (Kegel exercises) may be very helpful, especially if there is a tendency to “tighten up” due to pain when having sex.

Sexual pleasure and intimacy can include many activities other than penetrative vaginal intercourse. Orgasm can be achieved by both partners through genital stimulation by other methods. Occasionally, more explicit directions are required than those implied here, and the help of a sex therapist can be a very helpful step taken by a couple.

Prescription medications
Systemic Hormone Replacement Therapy (Estrogen With or Without Progesterone)
Estrogen is the oldest, most effective prescription drug for the treatment of vaginal dryness (and other menopausal symptoms). It comes in oral, transdermal patch, vaginal ring, spray, and gel formulations. These formulations made from a group of related estrogens including conjugated equine estrogen (CEE), synthetic conjugated estrogens, micronized 17b-estradiol, and ethinyl estradiol.

In women who still have a uterus, these drugs should be used with a progestogen (progesterone) because estrogen alone increases the risk of endometrial hyperplasia and cancer. The exception is a drug called Duavee (conjugated estrogens/bazedoxifene). In this formulation, conjugated estrogen is paired with a selective estrogen receptor modulator (SERM) that protects the uterus. In general, it is recommended the lowest dose of hormones for the shortest duration possible be used.

Oral estrogen is highly effective in treating the local genital and urinary symptoms of menopause, as well. The Women's Health Initiative (WHI) study scared many women and doctors away from the use of estrogen. This study enrolled around 27,000 women and had two treatment arms. In one arm conjugated equine estrogens (CEE) were used alone and in the other arm CEE was used together with a synthetic progestin called medroxyprogesterone acetate (MPA). Both of these groups were compared with a placebo group, which took neither drug.

The results of the study showed an increased risk of stroke and deep venous thrombosis (blood clots in the legs) in the CEE group with a decreased risk of hip, vertebral, and wrist fractures. There was no difference in overall mortality. The results also showed that the CEE+MPA group had an increased risk of stroke, pulmonary embolism (blood clots in the lungs), deep venous thrombosis (blood clots in the legs), and invasive breast cancer with a decreased risk of hip, vertebral, and wrist fractures. The CEE+MPA group also showed no difference in overall mortality.

However, the negative effects identified in this study differed based on the woman's age. In women ages 50–59 who are fewer than 10 years postmenopausal and who don't have contraindications, the risk of complications was not increased. Moreover, there seemed to be a benefit on total mortality (although it did not reach statistical significance).

Also, the WHI study was done with different chemicals than the ones naturally produced. The form of estrogen found in the body is call 17-beta estradiol and the form of progesterone is progesterone. These molecules are different than CEE and MPA used in the WHI study. Estradiol and micronized progesterone (both now commercially available) are identical to the natural hormones produced by the body. It is possible that the risks found in the WHI study would not be present with these hormones, but at present this is not known.

2) Ospemifene is daily tablet (taken by mouth) used to treat painful intercourse caused by vaginal atrophy. It is an estrogen agonist/antagonist, which means it works like estrogen (in places where you want more estrogen) and opposes estrogen's effect (in places where estrogen could cause harm).   

3) Dehydroepiandrosterone (DHEA) also treats vaginal atrophy but is placed in the vagina. Even though it can be converted into estrogen in the body, blood levels of estrogen do not seem to rise when it is used.