With all the changes that menopause brings, did you really think your vagina would be an exception? Luckily we’ve got just the thing to help: an excerpt from Sexual Health & Menopause, a new online resource from The North American Menopause Society (NAMS), that explains what to expect and how best to deal with it. For more information, checkout the complete guide, which includes tables and illustrations, on the NAMS website.
Dial in on Discomfort
Shifting levels of hormones—especially estrogen—during the menopause transition produce changes in a woman’s body. Both the vagina and the external female genitals (vulva) are affected. Two common changes are vulvovaginal atrophy and atrophic vaginitis.
- Vulvovaginal atrophy. During perimenopause, less estrogen may cause the tissues of the vulva and the lining of the vagina to become thinner, drier, and less elastic or flexible—a condition known as vulvovaginal atrophy. Vaginal secretions are reduced, resulting in decreased lubrication. Reduced levels of estrogen also result in an increase in vaginal pH, which makes the vagina less acidic, just as it was before puberty.
Continuing to have regular vaginal sexual activity through menopause helps to preserve the thickness and moisture of vaginal tissues and maintain the vagina’s length and width. This helps keep sexual activity pleasurable.
- Atrophic vaginitis.When “–itis” is added to a word, it generally means inflammation. Inflammation of the vagina after menopause in a woman who is not using hormone therapy is called atrophic vaginitis. This condition can include redness of the vagina and vaginal discharge. It’s associated with the loss of estrogen after menopause and usually improves with the use of low doses of vaginal estrogen therapy.
Keep Sex Comfortable
If you are having mild vulvar irritation or discomfort, the first thing to do is stop using soap on the inner parts of the vulva—clean water is perfectly adequate. Also, use only white unscented toilet paper, wash your underwear in detergents without dyes and perfumes, and discontinue using fabric softeners and anti-cling laundry products. Avoid using lotions and perfumed products on the inner vulva as well.
Menopause-related vaginal dryness often leads to pain with penetration and during deep intercourse, and can be associated with arousal difficulties as well. Many different topical vaginal treatments are available, from nonprescription, nonmedicated lubricants and moisturizers to prescription-only topical forms of estrogen therapy (see table).
Lubricants and moisturizers are effective in relieving pain during intercourse for many midlife women with mild to moderate vaginal dryness, so these products are a natural place to start. That’s particularly the case for women who are not candidates for vaginal estrogen therapy or are not comfortable using it.
If you have more severe vaginal dryness and related pain, or if lubricants and moisturizers don’t work well for you, see your healthcare provider.
- Moisturizers. Like lubricants, vaginal moisturizers reduce the painful friction that sex can cause as a result of vaginal atrophy. Additionally, moisturizers, unlike lubricants, are absorbed into the skin and cling to the vaginal lining in a way that mimics natural secretions. Another difference is that moisturizers are applied regularly, not just before sex, and their effects are more long-term, lasting up to 3 or 4 days. Some moisturizers have an applicator to help place the product into the vagina.
- Low-dose vaginal estrogen therapy. Estrogen products designed for vaginal application have been proven to restore vaginal blood flow and improve the thickness and stretchiness of vaginal tissue in peri- and postmenopausal women. These products act to reverse the thinning and dryness of vaginal tissues rather than just providing the temporary relief that lubricants and moisturizers do. For this reason, low-dose vaginal estrogen is appropriate in most cases for peri- and postmenopausal women who do not get sufficient relief from moisturizers or lubricants or whose symptoms of vaginal atrophy are interfering with their quality of life.
Vaginal estrogen should be used at the lowest effective dose, again to limit any effects elsewhere in the body. If you’ve had breast cancer, be sure to mention this to your healthcare provider before using estrogen in any form so that you can properly weigh its benefits and risks.
Low-dose vaginal estrogen is very effective against atrophy-related pain during sex, with up to 93% of women reporting significant improvement and 57% to 75% reporting that their sexual comfort is restored. Improvements in vaginal moisture and health typically occur within a few weeks of starting therapy, although relief from severe vaginal atrophy can take several months.
All forms of vaginal estrogen are similarly effective, and most forms are associated with minimal side effects, although women’s individual responses may differ. The form chosen should be based on your individual preference, factoring in cost and insurance coverage, after discussion with your healthcare provider.
If low-dose vaginal estrogen therapy is right for you, you may also use lubricants and moisturizers as needed. Sometimes, after estrogen therapy has restored the vaginal tissues to a more healthy state, it can be stopped and nonhormonal lubricants or moisturizers can be used alone. To maintain the benefit, however, it is important to continue regular vaginal sexual activity.
Visit the NAMS Sexual Health and Menopause online module for more!