Vaginal dryness is the most bothersome symptom of the menopause – in addition to hot flashes. It is also the one that is most ignored by women and least effectively treated by doctors, even though it affects quality of life so severely and even though excellent treatment exists.
Vaginal dryness is the most bothersome symptom of the menopause – in addition to hot flashes. It is also the one that is most ignored by women and least effectively treated by doctors, even though it affects quality of life so severely and even though excellent treatment exists.
There is a progressive drop in the level of estrogen in the body as you go through menopause. Several changes like hot flashes, mood swings, body ache tend to settle as the years pass. However, vaginal dryness due to low estrogen levels tends to continue to be bothersome and even get worse as age advances.
Decreasing estrogen levels cause the vagina to become dry, inelastic and thinned out. This is called atrophy. Studies show that vaginal atrophy is present in over 34% of women as they go through menopause and over 80% of post-menopausal women have some symptoms relating to vaginal dryness.
If you find talking about intimate issues embarrassing, you are not alone. Over 77% of women find talking about vaginal dryness uncomfortable and even in countries like the US, Canada and UK 42% of women did not know that vaginal dryness treatment exists.
Many women who do pick up the courage to talk about vaginal dryness symptoms don’t always get the treatment they need. Studies found that over 63% of women who had symptoms of vaginal dryness and atrophy had never been prescribed treatment. Yet, the same studies showed that 67% of those treated reported positive effects.
In this article we will talk about the different causes of vaginal dryness (focusing on menopause), the effects it can have on quality of life, the treatments currently available and some newer treatments that should become available soon. We will also talk about home remedies, non-hormonal treatments and some strategies to make these treatments work for you.
Vaginal dryness – causes
There are several reasons for vaginal dryness. Some reasons can happen along side menopause and complicate both the presentation and treatment.
- Decreasing estrogen and androgens as you go through menopause.
- Surgical menopause caused by a hysterectomy where the ovaries are removed.
- Medication you may be taking – anti allergy tablets, tablets for urinary incontinence, some antidepressants.
- Radiation or chemotherapy for cancer treatment.
- Anti-estrogen medication used to treat endometriosis or uterine fibroids.
- Certain illnesses that have dryness as a part of their presentation – e.g Sjogren’s syndrome.
- Emotional or psychological issues – stress, anxiety, depression, loss of desire, pain during sex.
- Diabetes mellitus can worsen symptoms of menopause and vaginal dryness in particular.
Symptoms of vaginal dryness
When the vagina loses the support of estrogen as you go through menopause, it becomes thinner and less elastic. If sex is infrequent, the vagina can become shorter and tighter and tear easily when you do have sex.
The drop in estrogen also affects the vulva, perineum and anus. These changes affecting the genitals in women who go through menopause are clubbed under the terminology – genitourinary syndrome of menopause.
Vaginal dryness is the symptom that women report as being most bothersome, second only to hot flashes.
The vagina and vulva can feel itchy and a burning sensation can cause distress. Even wearing underwear can sometimes become uncomfortable.
Some women report burning when passing urine or stools or a sensation of urgency or having to go often. Other bothersome symptoms are urinary incontinence, burning and stinging when passing urine, and pain with intercourse.
Vaginal dryness during sex can cause it to become painful and distressing and there starts a vicious cycle of pain – loss of arousal – no orgasm – loss of desire – relationship stress- anger- fear- loss of intimacy – loss of desire – and the cycle continues only to deteriorate with age.
Women don’t talk about painful intercourse or vaginal dryness during intercourse, because they feel embarrassed. When questioned, over 40% admit to having pain with sex – this is called dyspareunia. These are the women who are still having sex! We know that over 50% of women simply stop having sex altogether or have sex very infrequently when they go through menopause. You can read more in my article about sex and menopause.
All these symptoms are worse in women who undergo treatment for cancer. The challenge lies in being able to achieve some relief from these bothersome symptoms without using hormone therapy that can aggravate hormone dependent cancers or cause them to recur. Eventually, treatment is more a matter of quality of life than just how it affects recurrence or survival.
Menopause and vaginal itching
As estrogen levels drop and the vagina becomes dryer and thinner, the cells also lose the usual glycogen content that special bacteria called lactobacilli love. This means that these bacteria no longer have the food they need to thrive and keep the pH of the vagina acidic.
As the pH of the vagina changes, so does the bacterial population – often called vaginal microbiome. This change can mean that fungus like candida grow more easily.
Vaginal itching at menopause can be simply because of the dryness and sensation of irritation or it can be because of an overgrowth of candida. This is particularly important if you suffer with diabetes or are taking antibiotics or steroids for other illnesses.
Menopause and vaginal discharge
As vaginal dryness sets in, the quality and quantity of vaginal discharge you experience changes.
Most women have a cyclicity to vaginal secretions that they get used to through their reproductive years. The clear discharge of the first half of the cycle compared to the thicker whiter discharge once you ovulate and the discharge associated with an expected period.
Once menopause sets in and estrogen levels decline, this cyclicity is lost. Although the vagina feels dry most of the time, there may still be a discharge of some kind. If an infection sets in, the discharge can become yellow and sticky and stain underwear. If it becomes smelly it is best to see a gynaecologist to get a diagnosis and appropriate treatment.
Menopause and vaginal odor
Most women are familiar with how their genitals smell. The smell that is normal for them comes from pheromones secreted from sweat glands on the vulva. Vaginal secretions also have typical smell although this is affected by what we eat and drink and whether there is an infection.
Menopause and the associated decreasing estrogen levels, changes the quality and quantity of sweat produced by the sweat glands on the vulva and also the vaginal secretions.
The normal bacteria that reside in the vagina and feed on glycogen, which is dependent on circulating estrogen now have a challenge. The drop in estrogen with menopause changes this bacterial population. This changes the quantity and quality of vaginal secretion.
If there is an infection, typically with bacteria from the anus – vaginal discharge can become smelly and discolored.
Generally speaking, postmenopausal vaginal dryness and discharge is likely to be an ongoing problem. It is best to seek treatment early and get reviewed regularly so that quality of life is not affected severely.
Vaginal dryness – diagnosis
A study found that vaginal dryness was the commonest complaint and worsens with age (upto 64% of women over the age of 55 years). This is followed by painful sex (54%), itching (38.5%), burning (38.3%) and pain when passing urine (29%)
When you see your doctor about menopause and symptoms that bother you do talk about vaginal dryness and how it affects you. The doctor will most likely also take a detailed medical and drug history to determine the cause. As we have already seen several other problems can be associated with vaginal dryness at menopause.
What the doctor uses to confirm the diagnosis is a visual inspection of the vulva and vagina so be prepared to have an internal examination. The vagina often looks dry and pale. Sometimes the examination itself can cause stretching and small tears that bleed easily – this is called mucosal fragility. These signs all become worse with age and if the change is associated with radiation or chemotherapy for cancer.
Some additional objective tests are the vaginal maturation index which looks at the changes in the cells of the vagina for the effects of estrogen. Vaginal pH measurement is also a marker of the level of estrogen in the cells. This is because in the presence of estrogen the vaginal cells hold glycogen. When the normal bacteria in the vagina break down glycogen for their purpose, it keeps the pH of the vagina acidic (between 3.5 and 4.5). When the pH remains acidic only certain types of bacteria can survive and they are the ones that constitute the normal vaginal microbiome.
When the pH of the vagina is disturbed because of lack of estrogen, douching, sexually transmitted infections, antibiotic use etc. other organisms like candida (a fungus) can take over and cause an infection.
If there are obvious signs of infection by the presence of a smelly discharge, redness and pain on examination, the doctor may also take a swab to check for infection. A pelvic floor assessment will also help at this point to decide if you need help with a physiotherapist.
Vaginal dryness treatment options
There are several treatment modalities available for managing the problems associated with vaginal dryness. Vaginal dryness is one of the earlier symptoms of decreasing estrogen levels that then lead to atrophic changes in the vagina.
We talked about atrophic changes as those that cause the vagina to shrink or tighten or become friable. These atrophic changes associated with decreasing estrogen levels tend to persist or worsen as you age. Suffice to say that vaginal atrophy is easier to prevent than treat
So, it appears that early diagnosis and treatment can make a big difference to the effect that vaginal dryness has on overall quality of life. Treatment can prevent the progressive damaging effects of low estrogen with ageing.
The mainstay of this condition has always been estrogen and associated hormones like progesterone, DHEA and testosterone. Estrogen helps to thicken the vagina, improve its flexibility and stop it from shrinking.
However, many women are concerned about the side effects of hormone therapy including risks of breast cancer, hyperplasia of the lining of the womb, strokes and heart disease.
Concerns about these side effects were raised over a decade ago and women have preferred to use complementary and alternative therapies to manage their symptoms.
Hormonal methods include oral, transdermal (with patches or gels on the skin), or vaginal preparations containing estrogen alone or in combination with progesterone, testosterone and DHEA (a hormone that acts as a precursor for estrogen and androgens in the body). Drugs like Bazedoxifine and Ospemifine are newer medicines that are being studied for the treatment of menopause symptoms. Vaginal oxytocin has also been studied as a treatment method.
Non-hormonal methods include herbal remedies, vitamins, vaginal moisturizers, oils and blended preparations, laser treatment, physiotherapy for the pelvic floor.
Psychosexual therapy and cognitive behavioral therapy have been used to improve sexual functioning and arousal by teaching the woman and her partner how to manage menopausal symptoms better and not allow them to affect intimacy and closeness.
Vaginal dryness home remedies
Women have used home remedies for centuries to combat the effects of vaginal dryness after menopause.
Some of these include using oils or petroleum jelly to moisturize the vulva and vagina and also as a lubricant for intercourse. Some common oils that women use are olive oil, coconut oil, jojoba oil and vitamin E containing oil capsules.
Many women take supplements advertised in magazines or recommended by friends. These often contain soya products as well as herbs claiming to have hormonal effects. I would suggest that you discuss any supplements or ‘natural’ sounding medicines with your doctor. Any herbal preparation can have interactions with existing medication or unpredictable hormonal effects.
Some lifestyle changes that can help are:
- Giving up smoking – smoking tends to aggravate menopausal symptoms and vaginal dryness in particular. It has damaging effects on collagen and elastin throughout the body and can worsen skin, hair and nail changes as well as changes to the genital area.
- Eliminating perfumed soap or deodorant use on the vulva, including scented panty liners. Use cotton underwear and be careful with heavily scented laundry detergent or fabric softeners.
- Have sex regularly – staying sexually active exercises the pelvic floor and keeps the vaginal flexible and lubricated. You can read more in my article about sex and menopause. (insert link)
- Exercise – regular physical exercise helps to improve pelvic and genital blood flow and preserves your ability to get aroused and experience orgasms.
- Nutrition and hydration – Good nutrition especially from a wide range of plants, good fats and lean protein allows your body to repair damage. Keeping hydrated also ensures that the mucosal surfaces in the body remain moisturized.
- Relationships – ensuring that intimate relationships get the attention they need and adapt to physical changes that come with ageing so that intimacy and romance is maintained.
- Learning how to masturbate – this can help with learning to get aroused and training the mind and body so that the vagina can lubricate naturally.
- Diabetes mellitus – diabetes worsens symptoms of menopause and vaginal dryness in particular. Vaginal Candida is worse in women with diabetes.
Pelvic floor physical therapy / physiotherapy
The pelvic floor is a complex organization of muscles that do more than just hold up your internal organs.
Poor pelvic floor muscle tone (either too tight or too loose) can be associated with problems with painful sex, bladder weakness and leaking, feces and flatus incontinence, prolapse of the internal genital organs, chronic pelvic pain, back and posture problems. Good pelvic floor health is essential for good genital wellbeing.
When we do things that exercise our pelvic floor, the blood flow to the muscles themselves and surrounding tissues increases. Several exercises like Yoga, Pilates, Taiichi, Martial Arts and several dance forms help to exercise the pelvic floor muscles.
Regular sex also keeps the pelvic floor toned.
Your doctor may prescribe pelvic floor physiotherapy to get you started on your way to better pelvic floor health. The physiotherapist may use additional tools in her repertoire to build muscle strength, tone and responsiveness.
Pelvic floor muscle physical therapy administered over 12 weeks along with local estrogen and olive oil for lubrication (OVERcome study) significantly improved symptoms of vaginal dryness an atrophy.
Use of dilators
In women who have undergone early menopause or had chemotherapy or radiotherapy for cancer, vaginal atrophy changes can be very marked. The vagina can become shortened and narrow and intercourse can become very painful and uncomfortable indeed. Even getting a simple gynecological assessment like a cervical smear can become difficult.
For these women the doctor may prescribe vaginal dilators to use along side local treatment with creams or gels.
Vaginal dilators can be made of different materials – glass, stainless steel, silicone, plastic. The come in graduated sizes increasing in 2 mm diameter. Usually, they are available as a set of 4 or 5 from small to large and are shaped so that they are easy to insert.
The doctor will train you on how to use the dilators and some do come with video instructions to follow. You will need to use a lubricating gel along with the dilators.
Counseling – psychosexual therapy, cognitive behavioral therapy (CBT)
Having great sex isn’t just about intercourse.
When you are young the vagina lubricates with visual and verbal triggers in anticipation of being with someone you are attracted to sexually.
As you age or go through menopause estrogen levels decline and getting aroused needs more effort on your part. Making an effort to get aroused properly before attempting intercourse can significantly improve comfort and enjoyment of sex.
If working on arousal doesn’t make things better you can use a lubricant to make sex comfortable.
Unfortunately, other factors influence arousal too.
A strained relationship can make getting aroused much harder. Anger, resentment, and bitterness in a relationship can kill sexual feelings and make getting aroused difficult and sex painful. In such cases counseling can help restore intimacy and love in the relationship.
Herbal preparations for vaginal dryness treatment
Many of the studies reporting about benefits of herbal preparations come from Iran. I have included the references at the end of this article. Some of the herbs studied are summarized below.
Fennel cream has shown positive effects on symptoms of vaginal dryness, itching and pain with intercourse. There isn’t sufficient data to support using fennel cream as a first line treatment because some studies did not improve atrophic changes although symptoms were better. This comes under the category called phytoestrogens.
This hasn’t been studied extensively. It didn’t have much effect on the actual structure of the vagina but did help to reduce some of the psychological distress associated with vaginal dryness.
Chamomile too hasn’t been studied extensively. In the one study that compared it to estrogen and placebo it had similar effects to estrogen. They found a reduction in symptoms of itching, pain with sex and vaginal irritation due to dryness.
Vaginal Phytoestrogens and isoflavones
Phyto estrogen means plant-based estrogen. They tend to have variable effects on the changes in the vagina. It has been difficult to quantify the effect in order to create a suitable preparation that guarantees results.
Pueraria mirifica is a plant that grows in Thailand and has been used for generations to improve health and vitality in men and women. This too is classed as a phytoestrogen and showed some positive effect on symptoms of vaginal dryness
Red clover oil
When used vaginally red clover oil showed some positive effects on the changes in the cells of the vagina but it wasn’t as good as estrogen.
This showed some benefit in improving changes of vaginal dryness and reduced painful sex by up to 27%.
This too showed minimal or no changes on vaginal dryness symptoms.
Vaginal probiotics have often been promoted as helping with restoring the vaginal microbiome that used to exist when you had normal estrogen levels. Antibiotics or drugs like ibuprofen, douching, washing excessively with soap can damage the delicate balance of the vaginal bacterial flora and women can end up with infections and irritation.
Common infections that appear when the vaginal microbiome is disturbed are Bacterial Vaginosis or BV and Candida or thrush. The symptoms associated with these infections are also similar to vaginal dryness caused by lack of estrogen. In order to manage these symptoms women have used home cultured yogurt and probiotic capsules meant for oral use to put in the vagina. They also try garlic cloves and tea tree oil to manage symptoms.
Unfortunately, there isn’t much evidence that these probiotics actually improve symptoms or signs of vaginal dryness and progressive atrophy – and this is what actually matters.
Future research could bring important probiotics in the market and there is a whole range of unique bacteria that could be used in conjunction with estrogen to prevent the changes of vaginal atrophy and ageing.
Vitamins and supplements
A number of vitamins and supplements have been studied for their effects on vaginal dryness and menopausal symptoms in general. Overall, any vitamins or supplements need to be taken with caution as their effects on other body systems and drug interactions are not explicitly stated. Do consult with your doctor before starting any new supplements.
There is only one study that looked at the effect of Royal Jelly cream on the symptoms of vaginal dryness and atrophy. When compared to estrogen it appears to have a similar effect. However, considering that the effect is similar to estrogen the concern is that it may have some hormonal effects comparable to estrogen. Whether it is safe for use by women who have undergone cancer treatment is still to be studied.
There were no adverse effects of using vitamin E vaginally. However, there were no benefits to using it orally for vaginal dryness either.
A vitamin D suppository was found to positively influence the cells of the vagina when used to treat vaginal dryness and atrophy. It also helped to lower vaginal pH and reduced pain with intercourse. There is insufficient data regarding the correct dose or duration of treatment.
Hyaluronic acid suppository was compared to Vitamin E and estrogen given vaginally. It was better than vitamin E and almost as good as estrogen in reducing the symptoms and signs associated with vaginal dryness and atrophy. It could be a good substitute for estrogen in women who are not eligible for hormonal treatment because of other reasons like hormone dependent cancers.
Vaginal hormone treatment
The various hormone treatments delivered vaginally are estrogen, DHEA, oxytocin and testosterone.
We know that estrogen produces the most significant effects in reducing vaginal dryness and the changes of atrophy.
The search for other hormones is for those women who cannot tolerate or cannot use estrogen because of their health conditions or because they have received treatment for hormone sensitive cancers (usually the breast or uterus).
Vagifem is an estrogen tablet (estradiol hemihydrate) that is to be inserted in the vagina once at night for two weeks then once or twice a week for six weeks. Maintenance is with one tablet vaginally once a week for up to one year. You can take a break and repeat the process. Presently, there isn’t much data on women who have used it for longer than one year continuously. The benefit of vagifem is that it is far less messy than using a cream.
Premarin vaginal estrogen cream
Premarin is a brand that has combined equine estrogen (CEE). The same estrogen that is in the tablet has been made into a cream that can be used vaginally. It comes with an applicator that needs to be loaded with cream (you can use different doses according to your prescription). The advantage of a cream with an applicator is that your doctor can prescribe the dose that is most appropriate for you depending upon the changes in the vagina.
Evalon vaginal estrogen cream
This is another cream with similar content to vagifem. This also comes with an applicator that can deliver the right dose.
Ultra low dose vaginal estrogen
This vaginal estrogen gel was developed particularly for women who could not tolerate the normal dosage of estrogen in creams or gels that were available in the market. This gel contains an ultra low dose of estrogen (0.005% or 50 ug compared with 0.5 mg or 1 mg of regular vaginal dryness cream like Evalon or Premarin). When used daily for 3 weeks and then twice a week fo 12 weeks, it significantly improved the objective signs of vaginal dryness and atrophy
Oxytocin vaginal gel
This gel in the dose of 400 IU daily vaginally for up to 8 weeks showed significant improvement in the symptoms of vaginal dryness as well as objective improvement in pH and vaginal maturation index. It seems to be a promising alternative for women who cannot use estrogen to treat vaginal dryness.
DHEA – dehydroepiandrosterone (DHEA or prasterone) is a precursor of androgens and estrogen in the body. It has been used to improve general as well as sexual wellness in many ways.
When used vaginally as a gel it produced a similar effect to using estrogen and relieved symptoms of vaginal dryness significantly. It is used in the dose of 6.5 mg (0.5%) intravaginally daily for 12 weeks.
Systemic medications to help with menopause vaginal dryness
If you have menopause symptoms that affect your physical health and psychological health in addition to vaginal dryness and atrophy, systemic or whole-body medication may be preferred. You can read more about menopause treatment here.
Systemic therapy can include treatment with estrogen, progesterone, testosterone, DHEA as well as non-hormonal medication (anti-depressants, clonidine and other medications to manage symptoms).
Systemic treatment can be administered as oral tablets, transdermal gels or patches or metered doses, nasal sprays and vaginal rings or pessaries.
We will talk about some newer medications available on the market that can improve symptoms of vaginal dryness. These are Ospemifene and Bazedoxifene.
Estrogen tablets, gels and patches
A variety of preparations that can be tailored to the individual are now available worldwide to treat menopausal symptoms. Guidance from the International Menopause Society suggests that estrogen therapy should be used to manage severe symptoms in the lowest dose required for the shortest duration needed.
Estrogen treatment can be combined with progesterone and testosterone for different indications and various preparations with these combinations are also available.
Vaginal estrogen is considered safe for use and this guidance does not apply to vaginal estrogen use although there are contraindications to that as well.
Sometimes, systemic estrogen does not have the expected effect on vaginal dryness and in such cases the doctor may prescribe vaginal estrogen in addition to systemic therapy.
This is available as gels, patches and implants for women with menopausal symptoms, particularly sexual symptoms such as low libido and lack of arousal or orgasm. Preparations for women are specially designed and doctors are advised not to use preparations that are used in men because of the risk of over dosing and its side effects (acne, excess hair growth, voice changes and lipid changes).
This drug (a selective estrogen receptor modulator) is an important development in the treatment of moderate to severe vaginal dryness and atrophy in menopause. It showed significant improvement in all the measures used to determine a beneficial effect, particularly in relieving painful sex. It has been tested in women with breast cancer for up to one year of use and seems to be safe. It also helped with maintaining bone mass.
It certainly has opened up options for women who cannot use estrogen to manage their distressing symptoms.
This also another drug from a group called tissue selective estrogen complex (TSEC) that was used along with combined equine estrogen (CEE) to treat vaginal dryness. The combination significantly improved all the markers of vaginal dryness and atrophy and relieved bothersome symptoms.
Local treatment with energy devices
A variety of treatments using energy devices were developed after their successful use in cosmetic dermatology on the face and neck. These include lasers and radiofrequency devices specifically designed to be used inside the vagina.
Initially they were developed to address several cosmetic problems of the vulva and vagina. The tightening effect is used to good effect to improve vaginal tone and tightness and to treat mild urinary stress incontinence. In trials the treatment showed significant improvement in vaginal dryness and atrophy and has been studied in different clinical scenarios.
Most importantly, because the treatment is free from local or systemic hormones, it is attractive to women who cannot or do not wish to use hormones to treat their vaginal dryness symptoms, but do not get much relief from herbal preparations or home remedies.
Laser therapy with Co2 laser significantly improved vaginal dryness and atrophy symptoms. It improved symptoms of painful intercourse, vaginal discharge, itching, dryness as well as urinary incontinence.
Depending upon the severity of symptoms, several sittings may be required to get the desired effect. Effects last up to one year and a repeat treatment can help restore the initial effects.
Dynamic quadripolar radiofrequency
This was found to be very safe and effective in treating symptoms of vaginal dryness and atrophy associated with menopause (genitourinary syndrome of menopause). It was used over a period of 12 months and showed an excellent safety profile. This treatment is yet to come to mainstream therapy across the world.
Vaginal dryness treatment – how to make it work for you
With such a wide range of treatments available it can be confusing to decide which one is right for you.
It is best to make this decision with the help of your doctor. Vaginal dryness is one symptom that persists well beyond just the menopausal period and treatment options can change as you age, whether or not other problems like bladder symptoms crop up.
There is a simple way to help you decide.
Here is how to implement the decision process and the treatment options so that they work for you.
1. Use a symptom tracker
Here you can see an example of a symptom tracker built in a spreadsheet. There are several available as apps too that you can use. Just highlight the most important symptoms for you and start tracking.
The benefit of tracking is that you can identify those that are most bothersome for you and help you to discuss them with your doctor. Take your chart with you when you go to see your doctor so that you have something objective to share.
2. See your doctor / gynaecologist for a diagnosis
It is very tempting to start treating yourself after reading an article like this on the internet. Or after talking to a friend or confidante. I would encourage you to take all that you have learnt and see your doctor or gynaecologist anyway.
You can discuss the options for treatment with the doctor. After all, some of the most effective treatments need a prescription and those that do not, probably have little effect anyway.
Besides, your doctor is more able to determine if you are eligible for hormone treatment based on your medical history and any contraindications to it. If you have had treatment for cancer other treatments may be more appropriate. If you do end up needing medication, it is far better to be under the care of a physician who knows what to expect in case something untoward happens.
3. Are you comfortable touching your genitals or putting medication inside your vagina?
This so important that it bears repeating.
For any vaginal treatment to work you first need to be comfortable touching your genitals and putting medication inside the vagina either with your fingers or with an applicator. If for any reason this doesn’t seem suitable for you tell your doctor first.
This is because local vaginal treatments in the form of moisturizers or hormone creams, gels, tablets etc. are often the first line of treatment for menopausal vaginal dryness.
If you are uncomfortable with this route this treatment option is not suitable for you right now. Things may change in future and you can always consider this option later.
4. Determine if other menopause symptoms are bothersome
If you have several other symptoms of the menopause that are bothersome and affecting your quality of life your doctor can determine the scale of severity using a Menopause Rating Scale. There are several versions of this and any one is ok to determine how severely your symptoms are affecting you. The symptom tracker you keep is also good for this purpose.
The reason for this is that vaginal dryness may be part of this symptom complex and may be treated with a variety of specific treatments such as oral estrogen, estrogen patches, rings or gels, androgens, other medications like Bazedoxefine, Tibolone, Ospemifene, oral probiotics or oral phytoestrogens.
Whichever medication you decide to start with, it is best to discuss the advantages and disadvantages, risks and benefits of them with your doctor. This includes the several home remedies and ‘natural’ products we talked about.
5. Vaginal dryness after cancer treatment
If you are suffering with vaginal dryness after receiving cancer treatment you fall into a special category and treatments need to be supervised carefully. You may be eligible for some local hormone treatments under the supervision of your oncologist.
Newer non-hormonal energy-based treatments like laser can give better relief of symptoms than home remedies alone. The treatment effect can be variable and be aware that several sittings may be required before you feel significant relief from vaginal dryness and discomfort.
Very often you can continue to use the different home remedies to give temporary relief of the itching and burning sensation that often accompanies vaginal dryness.
6. Using local non-hormonal treatments
You can first try non-hormonal local treatments if you are comfortable with touching your genitals and inserting your fingers or applicators into the vagina.
Vaginal dryness creams can include moisturizers, lubricants, vaginal probiotics and vaginal phytoestrogens. We have discussed these in detail above.
The best lubricant for vaginal dryness is a water-based lubricant because it is less likely to cause allergies or alter the vaginal microbiome. A water-based lubricant can also be used with sex toys without worrying about damaging them.
There is limited data available for how well vaginal probiotics and phytoestrogens work. It is best to track your symptoms in the tracker to determine if you are getting the relief you need.
Remember, treatment with vaginal estrogen cream, tablet or ring is very safe and highly effective. Eventually, nothing works quite as well as estrogen. Your doctor can help you determine if it is safe for you to use estrogen vaginally to treat your symptoms of vaginal dryness and discomfort.
7. Lifestyle interventions
As a part of managing your symptoms put into place the lifestyle interventions we discussed earlier. These are supportive of any medical treatment you undertake. Stopping smoking and resuming exercise make a difference to your overall health as well as in improving symptoms of menopause. If you are obese or overweight, consider looking for support to help you release your excess weight and get fit. You can read more about weight gain in menopause here.
Diabetes mellitus can make vaginal symptoms much worse and be associated with severe candida infections. Consult your doctor regarding a diabetes check up and put into place the system you need to get it under control.
8. Sex and relationships
Various methods like Cognitive behavioral therapy (CBT) and Psychosexual therapy are used to intervene when relationships are strained due to poor sexual interactions. Painful sex can be a turn off and affect interpersonal communication. You can read more about sex and menopause here.
It really helps to include your partner in the treatment process and help him to understand the problems associated with menopause symptoms and lack of estrogen. He is much more able to participate in the treatment process. Intimacy can be restored and treatment can help you to enjoy sex without discomfort.
If you think you are experiencing difficulty in your sexual relationship as a result of vaginal dryness, pain and discomfort in spite of treatment do talk to your doctor about a referral for therapy. Just being able to talk openly about the problem can do wonders for your sex life.
Vaginal dryness and atrophy (Vulvovaginal atrophy -VVA) is a chronic medical condition that is one of the most bothersome symptoms of the menopause.
It has a significant negative effect on quality of life. Vaginal dryness and atrophy is associated with itching, burning, pain with intercourse and urinary problems.
In spite of how common it is (over 35% of menopausal women and over 65% of women over the age of 55) it is poorly managed.
Considering that this problem does not get better with time and can damage vaginal health and structure it needs to be addressed early so problems can be prevented.
It is important to address lifestyle issues and relationship stress alongside seeking medical treatment.
A variety of medical treatments are now available – systemic and local, hormonal and non-hormonal. They can significantly reduce the effect of vaginal dryness and atrophy on quality of life especially in menopausal women.
Women who have undergone treatment for cancer with chemo or radiotherapy suffer much worse symptoms of vaginal dryness and treatment options are limited if their cancer was hormone dependent.
Newer drugs and local energy treatments can significantly improve quality of life for these women and they should consult their doctor early and talk about these issues.
Estrogen therapy remains the most effective treatment for moderate to severe symptoms and ultra low dose medication is also now available.
Don’t hesitate to ask your doctor about this if your home remedies and natural preparations do not give you the relief you need to improve your quality of life. Now that you have the information you need and can use a symptom tracker, you can approach your doctor with confidence that vaginal dryness and its associated symptoms can be treated effectively.
I hope you have found this article useful and will put into use the tips I have shared to make vaginal dryness treatment work for you.
Do write to me at firstname.lastname@example.org with your thoughts.
Urogenital Prolapse and Atrophy at Menopause: A Prevalence Study. Versi, E., Harvey, MA., Cardozo, L. et al. Int Urogynecol J 12, 107–110 (2001). https://doi.org/10.1007/s001920170074
Women’s voices in the menopause: results from an international survey on vaginal atrophy Rossella E Nappi 1, Marta Kokot-Kierepa . Maturitas. 2010 Nov;67(3):233-8. doi:10.1016/j.maturitas.2010.08.001. Epub 2010 Sep 9. https://pubmed.ncbi.nlm.nih.gov/20828948/
Vaginal atrophy across the menopausal age: results from the ANGEL study A Cagnacci 1, A Xholli 1, M Sclauzero, M Venier, F Palma, M Gambacciani, writing group of the ANGEL study. Climacteric. 2019 Feb;22(1):85-89. doi: 10.1080/13697137.2018.1529748. Epub 2019 Jan 2. https://pubmed.ncbi.nlm.nih.gov/30601037/#:~:text=Results%3A%20VA%20was%20diagnosed%20in,isolated%20VA%20symptoms%20or%20signs.
The most bothersome symptom of vaginal atrophy: Evidence from the observational AGATA study. Federica Palma, Anjeza Xholli, Angelo Cagnacci, as the writing group of the AGATA study. Maturitas. 2018 Feb;108:18-23. doi: 10.1016/j.maturitas.2017.11.007. Epub 2017 Nov 10. https://pubmed.ncbi.nlm.nih.gov/29290210/
The Efficacy and Safety of Ospemifene in Treating Dyspareunia Associated with Postmenopausal Vulvar and Vaginal Atrophy: A Systematic Review and Meta-Analysis Yuanshan Cui, MD, Huantao Zong, MD, Huilei Yan, MD, Nan Li, MD, and Yong Z. https://www.researchgate.net/profile/Yuanshan-Cui-2/publication/258764873_The_Efficacy_and_Safety_of_Ospemifene_in_Treating_Dyspareunia_Associated_with_Postmenopausal_Vulvar_and_Vaginal_Atrophy_A_Systematic_Review_and_Meta-Analysis/links/5f313b4a92851cd302ec0609/The-Efficacy-and-Safety-of-Ospemifene-in-Treating-Dyspareunia-Associated-with-Postmenopausal-Vulvar-and-Vaginal-Atrophy-A-Systematic-Review-and-Meta-Analysis.pdf
A Review of Pharmacological Treatments for Vaginal Atrophy in Postmenopausal Women in Iran. Farzaneh Rashidi Fakari, Masoumeh Simbar, Maryam Beheshti Nasab, Masoumeh Ghazanfarpour, and Fahimeh Rashidi Fakari. J Menopausal Med. 2020 Aug; 26(2): 104–111.Published online 2020 Jul 24. doi: 10.6118/jmm.19021
Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society Menopause. 2013 Sep;20(9):888-902; quiz 903-4. doi: 10.1097/GME.0b013e3182a122c2. https://pubmed.ncbi.nlm.nih.gov/23985562/
Quality of life and sexual function of naturally postmenopausal women on an ultralow-concentration estriol vaginal gel. Salvatore Caruso, Stefano Cianci, Francesca F Amore, Betty Ventura, Elisa Bambili, Saveria Spadola, Antonio Cianci Menopause. 2016 Jan;23(1):47-54. doi: 10.1097/GME.0000000000000485.
Effect of Intravaginal Prasterone on Sexual Dysfunction in Postmenopausal Women with Vulvovaginal Atrophy. Fernand Labrie, Leonard Derogatis, David F Archer, William Koltun, Andrée Vachon, Douglas Young, Louise Frenette, David Portman, Marlene Montesino, Isabelle Côté , Julie Parent, Lyne Lavoie 1, Adam Beauregard 1, Céline Martel 1, Mario Vaillancourt 1, John Balser 9, Érick Moyneur, Members of the VVA Prasterone Research Group J Sex Med. 2015 Dec;12(12):2401-12. doi: 10.1111/jsm.13045. Epub 2015 Nov 23. https://pubmed.ncbi.nlm.nih.gov/26597311/
An overview of the phytoestrogen effect on vaginal health and dyspareunia in peri- and post-menopausal women. Fatemeh R Dizavandi, Masoumeh Ghazanfarpour, Nasibeh Roozbeh, Leila Kargarfard, Talat Khadivzadeh, Sareh Dashti. Post Reprod Health. 2019 Mar;25(1):11-20. doi: 10.1177/2053369118823365. Epub 2019 Feb 20. https://pubmed.ncbi.nlm.nih.gov/30786797/
Effect of Foeniculum vulgare (fennel) vaginal cream on vaginal atrophy in postmenopausal women: A double-blind randomized placebo-controlled trialMasomeh Yaralizadeh 1, Parvin Abedi 2, Shahnaz Najar, Foroogh Namjoyan, Amal SakiMaturitas. 2016 Feb;84:75-80. doi: 10.1016/j.maturitas.2015.11.005. Epub 2015 Nov 12.
Fractional CO2 Laser for Treatment of Vulvovaginal Atrophy: A Short Time Follow-upZinat Ghanbari, Samira Sohbati, Tahereh Eftekhar, Leyla Sahebi, Soodabeh Darvish, Safa Alasiri, Marayam Deldar Pasikhani . J Family Reprod Health. 2020 Jun;14(2):68-73. doi: 10.18502/jfrh.v14i2.4347.
The Effect of the CO 2 Fractional Laser or Premarin Vaginal Cream on Improving Sexual Function in Menopausal Women: A Randomized Controlled Trial. Tahereh Eftekhar, Tahereh Forooghifar , Tahereh Khalili, Mamak Shariat, Fedyeh Haghollahi. J Lasers Med Sci. Summer 2020;11(3):292-298. doi: 10.34172/jlms.2020.49. Epub 2020 Jun 21.
Sexual Function in Women Suffering From Genitourinary Syndrome of Menopause Treated With Fractionated CO 2 Laser. Stefano Salvatore, Eleni Pitsouni, Fabio Del Deo, Marta Parma, Stavros Athanasiou, Massimo Candiani. Sex Med Rev. 2017 Oct;5(4):486-494.doi: 10.1016/j.sxmr.2017.07.003. Epub 2017 Aug 23.
A randomized, placebo- and active-controlled trial of bazedoxifene/conjugated estrogens for treatment of moderate to severe vulvar/vaginal atrophy in postmenopausal womenRisa Kagan 1, R Stan Williams, Kaijie Pan, Sebastian Mirkin, James H Pickar. Menopause. 2010 Mar;17(2):281-9. doi: 10.1097/GME.0b013e3181b7c65f. https://pubmed.ncbi.nlm.nih.gov/19779382/
Dynamic quadripolar radiofrequency treatment of vaginal laxity/menopausal vulvo-vaginal atrophy: 12-month efficacy and safety. Franco Vicariotto, Francesco DE Seta, Valentina Faoro, Mauro Raichi. Minerva Ginecol. 2017 Aug;69(4):342-349. doi: 10.23736/S0026-4784.17.04072-2. https://pubmed.ncbi.nlm.nih.gov/28608667/
The acceptability, feasibility, and efficacy (phase I/II study) of the OVERcome (Olive Oil, Vaginal Exercise, and MoisturizeR) intervention to improve dyspareunia and alleviate sexual problems in women with breast cancer. Ilona Juraskova, Sherin Jarvis, Kelly Mok, Michelle Peate, Bettina Meiser, Benjamin C Cheah, Shab Mireskandari, Michael Friedlander. J Sex Med. 2013 Oct;10(10):2549-58. doi: 10.1111/jsm.12156. Epub 2013 May 1. https://pubmed.ncbi.nlm.nih.gov/23635341/
The role of androgens in the treatment of genitourinary syndrome of menopause (GSM): International Society for the Study of Women’s Sexual Health (ISSWSH) expert consensus panel reviewJames A Simon, Irwin Goldstein, Noel N Kim, Susan R Davis, Susan Kellogg-Spadt, Lior Lowenstein, JoAnn V Pinkerton, Cynthia A Stuenkel, Abdulmaged M Traish, David F Archer, Gloria Bachmann, Andrew T Goldstein, Rossella E Nappi, Linda Vignozzi. Menopause. 2018 Jul;25(7):837-847. doi: 10.1097/GME.0000000000001138.https://pubmed.ncbi.nlm.nih.gov/29870471/
Ospemifene for the treatment of vulvovaginal atrophy and dyspareunia in postmenopausal womenAmber N McLendon, Valerie B Clinard, C Brock Woodis Pharmacotherapy. 2014 Oct;34(10):1050-60. doi: 10.1002/phar.1465. Epub 2014 Jul 23.https://pubmed.ncbi.nlm.nih.gov/25052122/
Ospemifene for the treatment of vulvar and vaginal atrophy: A meta-analysis of randomized trials. Part I: Evaluation of efficacy. Violante Di Donato, Michele Carlo Schiavi, Valentina Iacobelli, Ottavia D’oria, Evangelos Kontopantelis, Tommaso Simoncini, Ludovico Muzii, Pierluigi Benedetti Panici. Maturitas. 2019 Mar;121:86-92. doi: 10.1016/j.maturitas.2018.11.016. Epub 2018 Nov 24.
Ospemifene for the treatment of vulvar and vaginal atrophy: A meta-analysis of randomized trials. Part II: Evaluation of tolerability and safety. Violante Di Donato, Michele Carlo Schiavi, Valentina Iacobelli, Ottavia D’oria, Evangelos Kontopantelis, Tommaso Simoncini, Ludovico Muzii, Pierluigi Benedetti Panici. Maturitas. 2019 Mar;121:93-100. doi: 10.1016/j.maturitas.2018.11.017. Epub 2018 Nov 28. https://pubmed.ncbi.nlm.nih.gov/30509754/
Efficacy and safety of ospemifene in postmenopausal women with moderate-to-severe vaginal dryness: a phase 3, randomized, double-blind, placebo-controlled, multicenter trialDavid F Archer, Steven R Goldstein, James A Simon, Arthur S Waldbaum, Steven A Sussman, Corrado Altomare, Julie Zhu, Yuki Yoshida, Sam Schaffer, Graziella Soulban.Menopause. 2019 Jan 28;26(6):611-621. doi: 10.1097/GME.0000000000001292.https://pubmed.ncbi.nlm.nih.gov/30694917/
The effect of oxytocin vaginal gel on vaginal atrophy in postmenopausal women: a randomized controlled trial Ilnaz Zohrabi, Parvin Abedi, Somayeh Ansari, Elham Maraghi, Nader Shakiba Maram, Gholamreza Houshmand. BMC Womens Health. 2020 May 19;20(1):108. doi: 10.1186/s12905-020-00935-5.https://pubmed.ncbi.nlm.nih.gov/32429977/