Dr. Phillips is Clinical Assistant Professor and Dr. Bachmann is Professor, Department of Obstetrics and Gynecology, and Professor of Medicine, Interim Chair of Obstetrics/Gynecolgy, Associate Dean for Women's Health and Chief of the OB/GYN Service at Robert Wood Johnson University Hospital, and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.
Menopause brings many unwelcome changes to women's skin. While cosmetic firms, plastic surgeons and women themselves are most focused on the changes happening to their faces — wrinkles, laugh lines, and a thinning and drying of the skin — the same thing is happening to genital tissues. The result is for many women just as unpleasant as facial changes.
During and post-menopause, declining estrogen levels may make sex painful and cause other distressing symptoms such as vaginal burning, irritation, and discharge. Collectively, these symptoms affect both the vagina and the vulva. The problem is known to doctors as vulvo-vaginal atrophy (VVA) or simply, vaginal atrophy.
Women, as they age, should not only request treatment for medical conditions, but also ways to prevent unwanted aging changes. For many, this includes addressing ways to keep the vaginal tissue healthy.
Roughly half of healthy women over age 60 experience one or more of these symptoms with up to 52% of those affected reporting these symptoms have a negative impact on their quality of life. An international survey of 4,246 women aged 55-65 found 39% of them experienced symptoms of vaginal atrophy. Two-thirds of the women described these symptoms as moderate to severe and 60% found these symptoms to impair their quality of life.
Available studies have shown that only 25% of symptomatic women will seek help for VVA, and a large majority of women (77%) are uncomfortable discussing these "personal" symptoms with their health care providers.
Menopausal women are not the only ones who experience VVA. Women of any age who have low estrogen levels may have symptoms. Disorders such as premature ovarian insufficiency, loss of menses from dieting or excessive exercise, surgical removal of the uterus, or prolonged lactation can contribute to women developing symptoms of vulvo-vaginal atrophy. So can medication side effects from cancer drugs and drugs that treat endometriosis;, for example, a GnRh agonist, aromatase inhibitor or chemotherapy.
Doctors can do more to bring the subject up during exams, asking patients directly about painful sex and sexual satisfaction. Women can improve the quality of their lives and sexual well being by being willing to discuss their symptoms with their doctors.
Before menopause the tissues — skin — of the vagina and vestibule are much like those covering our bodies. The cells form a strong, elastic, covering. Estrogen helps maintain these vaginal tissues. And the low vaginal pH (2.8 to 4) provides a good acidic environment for normal vaginal flora to thrive, which protect from many vaginal infections.
Pain during sex is one of the main reasons women seek help for VVA.
The normal level of estrogen improves blood flow to the gentials. If you have less estrogen and therefore less blood flow, your vagina will have fewer secretions, as well as delayed and reduced lubrication with sexual stimulation. The collagen content of the connective tissue also decreases, resulting in decreased elasticity.
The tissues of the vagina, clitoris and labia may thin and become more delicate. In some women, especially those who are not sexually active, the vaginal canal and its entrance may become more narrow.
As women age, these symptoms may become more bothersome. This means that as she ages, a menopausal woman who has had no discomfort or other symptoms may develop troublesome symptoms later.
Your health care provider may initiate a conversation about VVA, since women are often reluctant to do so, but don't wait. You are the authority and treatment can really make a difference.
The typical sorts of symptoms women report include vaginal dryness, burning or itching, and abnormal vaginal discharge. Urinary problems can also occur, such as urinary frequency, urgency or painful urination.
Pain during sex is perhaps one of the main reasons women seek help for VVA. When women experience pain during sexual activity, diminished arousal or decreased desire are often the result.
It would be a mistake, however, to see VVA as only a sexual complaint. As dramatized by actors in our first video "patient-physician" office visit below, even activities ranging from vigorous exercise to simply wearing fitted clothing may elicit vaginal discomfort. (Please note, all the patients in the videos below are actors.)
Your doctor will want to know what, if any, medications you are taking, as well as any medical conditions, prior sexual problems or of any soaps, detergents, over-the-counter remedies or other irritants you may be using which may contribute to vaginal symptoms.
Not all women find vaginal atrophy to be a problem. But if you are distressed by the symptoms and desire intervention, over-the-counter, non-hormonal products are the first line of help. If these are not effective, local vaginal estrogen is an FDA-approved therapy that has proven effective. Systemic estrogen, estrogen taken orally as in hormone therapy, should not be used for symptoms that involve vaginal atrophy only. For those with moderate to severe painful intercourse from menopausal VVA, ospemifene, a new, FDA-approved oral option, can also be prescribed.
Vaginal lubricants and moisturizers are the best place to start. They are available over-the-counter and are used to relieve symptoms for a short period of time, most often during sexual intercourse. They are applied locally and act immediately.
Vaginal lubricants can be water- , silicone- or oil-based. The oil-based, or petroleum-containing lubricants, interfere with condom integrity, and although pregnancy is not a concern for post-menopausal women, protection from sexually transmitted infection may be. Women who experience irritation from lubricants should be encouraged to find preservative–free solutions, even vegetable or mineral oil (see Table 1).
- Water-based Lubricants: Astroglide*, K-Y Gel*, Summer’s Eve*, Pre-seed*
- Silicone-based Lubricants: ID Lube Millennium, Pink*, Pjur
- Oil-based Lubricants: Elegance Woman’s Lubricant, mineral oil, vegetable oil
- Vaginal Moisturizers: Replens, Moist Again*, K-Y Silk-E
In contrast to vaginal lubricants, vaginal moisturizers are applied regularly, not just with or in anticipation of coital or other vaginal irritative activity. Moisturizers provide longer lasting relief of vaginal dryness. They are bio-adhesive and attach to vaginal epithelium, retaining water and helping restore the acidity of the vagina. Studies have shown increased transient lubrication with moisturizers and decreased discomfort during intercourse, but studies comparing vaginal moisturizers to local estrogen have almost uniformly found better long-term symptom relief with estrogens.(11)(13)
Products which add heating sensations, other arousal enhancers or topical herbal preparations are successful in some women. They may cause irritation and should be tried initially in very small quantities.
The main treatment for vaginal atrophy is estrogen, delivered locally. Estrogen restores the vaginal tissues to their premenopausal state — tissue thickens and elasticity increases, as does blood flow.
Local therapy reduces the risk to the liver since it does not need to be metabolized and it offers lower systemic hormone levels. It is probably the best choice for women with only vaginal symptoms.
Many women find estrogen-containing tablets convenient. They are used two or three times a week.
In the US, locally applied estrogen is available in cream, tablet and ring form (see Table 2). The estrogen-containing vaginal ring delivers the lowest dose of estrogen (7.5 micrograms estradiol daily), remains in place for 90 days and may need to be removed for sexual activity.
Many women find estrogen-containing tablets convenient. They are used two or three times a week. Conjugated estrogen vaginal cream is recommended at .5 mg dosage two to three times a week. An estradiol cream is recommended at 1 g twice a week.
These preventive low-dose local estrogen treatments can help forestall the development of VVA. Even women on systemic estrogen therapy may need local estrogen treatment if vaginal symptoms persist.
But even women taking hormones internally may need local treatment. Our third patient, who is young, healthy and pelvic pain-free after hysterectomy for endometriosis, attention to local vaginal health is essential to restore pain-free sexual function, despite systemic hormonal treatment.
| PRODUCT | COMPOSITION | DOSE |
|---|---|---|
| Vaginal Creams | ||
| Estrace Vaginal Cream | 17β-estradiol | Initial: 2–4 g/d for 1–2 weeks Maintenance: .5-1 g 1-2/week |
| Premarin Vaginal Cream | Conjugated estrogens | .5–2 g/daily |
| Vaginal Rings | ||
| Estring | 17β-estradiol | 7.5 microgram/d for 90 days |
| Femring | Estradiol acetate | .05-.1 mg/d estradiol for 90 days |
| Vaginal Tablet | ||
| Vagifem | Estradiol hemihydrates | Initial: 1 tablet (10 mcg)/d for 2 weeks Maintenance: 1 tablet (10 mcg) twice a week |
It may be necessary at the start of therapy to use higher doses and more frequent doses for relief. This should be followed by gradual tapering off to the recommended FDA dosing. When symptoms are severe, such as if small, open, vulvar fissures have appeared, estrogen creams may be applied topically as well as intra-vaginally until the symptoms go away and healing occurs, at which point the dose should be reduced to the lowest effective level.
How much vaginally delivered estrogen is absorbed into the body depends, of course, on the dose a woman is using. Endometrial and breast tissues can be stimulated by estrogen used vaginally, and this may become a concern as the longevity of use and dose increase. But when local estrogen is prescribed at FDA-approved dosages, studies have found that systemic estrogen levels usually do not exceed the levels occurring naturally in post-menopausal women.()
Similarly, studies investigating endometrial thickness do not find significant change with use of external vaginal estrogen preparations, regardless of the method of delivery. Though long-term data are not available, a review of estrogen use in post-menopausal women found no significant differences among the delivery methods (ring, tablet, cream) in terms of excessive endometrial cell growth or thickening or the proportion of women with adverse events.
There is no current recommendation for progesterone supplementation in women with an intact uterus or for endometrial screening. Any vaginal bleeding should be promptly evaluated.
For women with a history of breast cancer, especially estrogen receptor positive, ER (+), tumors, an increase in serum estradiol levels may not be acceptable.
There is some evidence that estradiol levels are higher at the initiation of local treatment, perhaps due to increased absorption through thin or broken epithelium. Additionally, higher levels of estradiol may be absorbed in the days immediately after placement of the vaginal ring, resulting in a spike of blood levels.
For most women, this estrogen spike is acceptable, as it is low and of short duration. However, in some women, even the potential for a change in serum estrogen levels is unacceptable to them. For example, for our 43-year-old video patient who has been treated for estrogen receptor positive breast cancer, both she and her oncologist may not want this to occur.
For women with a history of breast cancer, especially estrogen receptor positive, ER (+), tumors, an increase in serum estradiol levels may not be acceptable, especially in the early months and years after diagnosis and treatment. Oncologists often prefer that women stay away from estrogens during this time period. Yet the premature symptoms of menopause that can occur as a result of chemotherapy or other treatment for the cancer can cause severe vulvo-vaginal atrophy symptoms which may have a significant negative emotional and sexual impact.
Women trying to balance the desire to reduce VVA symptoms with treatment for breast cancer need to should discuss the risks and benefits of local estrogen therapy with their doctors and oncologists. Other women who, for reasons of limited mobility, such as those with arthritis, may seek therapies other than locally applied treatments.
A new drug was approved for the treatment of painful intercourse caused by vulvo-vaginal atrophy in February 2013. Ospemifene is an oral selective estrogen receptor modulator (SERM) that acts (beneficially) like estrogen, in this instance on the vaginal tissue, without also setting in motion estrogen's negative effects on other organs, e.g., uterus. Its side effects include hot flushes and potential risk of blood clots.
Ospemifene can be helpful for women who have not had the desired results with vaginal estrogen use to improve symptoms of painful intercourse or who are unable or unwilling to use vaginal preparations for treatment of sexual pain symptoms. This includes women with disabling arthritis or limited mobility where insertion of any vaginal product is difficult or impossible.
Other SERMs, such as tamoxifen and raloxifen, have beneficial safety profiles for breast cancer and osteoporosis but not for VVA symptoms. Preliminary animal data suggest that ospemifene has no effect on the breast tissue.. There is limited information on bone effects. Currently, there are not enough data to recommend its use in women with a personal history of breast cancer, or to support its use for breast or bone health.
Conclusion
Vulvo-vaginal atrophy is the underlying cause of many vaginal and sexual problems in the post-menopausal population. There is no reason for any menopausal woman to stop having sexual contact because of vaginal discomfort. In most cases, there is an intervention for all women that will sufficiently reduce painful symptoms enough to enable full sexual functioning. The first step is for women experiencing VVA to actively seek out their health care providers' help to find the best way to treat their VVA symptoms and improve their sexual and overall health.
