Vaginal Dryness and Painful Sex after Menopause
Menopause is a stage in a woman’s life after her ovaries stop producing eggs and hormones. It is a natural event, occurring around the age of 50. The ovaries produce the female hormones estrogen and progesterone associated with ovulation. At menopause, there is no further production of estrogen by the ovaries. The lack of estrogen in menopause is often associated with the systemic symptoms of hot flashes, night sweats, and insomnia. The vagina depends on estrogen to support the vaginal lining – the vaginal mucosa. Without sufficient estrogen support, the vaginal mucosa thins down – the atrophic change – and decreases in fluid production to moisturize and lubricate the vagina, especially during sex. The thinning of, and the lack of fluid from the vagina contribute to painful sex.
Sexual activities actually promote blood flow to the vagina and keep the vaginal mucosa thick and moist. Unfortunately, with the vaginal atrophy and dryness causing painful sex, one might even avoid sex. This sets up a vicious circle – more pain and dryness, less sex; less sex, more thinning, dryness and pain, then even lesser sex. The vicious circle needs to stop.
Systemic estrogen replacement therapy, whether orally or transdermal, might help the vaginal atrophy and dryness. Other estrogen like drugs such as Osphena also might help. However, both drugs carry cancer or thrombosis (blood clot) risks, and they are not always effective in taking care of vaginal dryness and painful sex. Women with a history of, or prone to breast or uterine cancer or thrombosis should not take estrogen systemically. Vaginal estrogen tablets, suppositories and rings work better to improve the vaginal mucosa locally, but still carry some cancer and thrombosis risks.
Over the years, I have found that by massaging a small quantity of estrogen vaginal cream – a quarter gram or less – into the vaginal tissue, using ones finger tip to do so over a minute, three times a week, the vaginal mucosa recovers quite well. I suspect the direct application to the target area with massaging to increase medication absorption and local blood flow help. Many women have reported improved vaginal moisture, lubrication and less painful sex. Women should consult with their physicians to see if this treatment is right for them, and without contraindication.
For patients that should not, or do not want to, use estrogen vaginally, there are over the counter preparations that can help with vaginal dryness or painful sex. One can use frequently a vaginal moisturizer that brings hydration locally to the vaginal tissue, without the concern of estrogen. For sexual activities, lubricant can then be used as needed.
There are several medical devices on the market, including the use of laser or RF energy, to help to “ rejuvenate” the vagina. The energy is used to stimulate the thickening of the vaginal mucosa and encourage moisture. However, the long-term duration of such effect is not certain, and the procedures are costly. Maybe they would be most suitable for women who had breast or uterine cancer and should not use estrogen.
Michael Lau, MD, FACS, FACOG