Did you know that intimate dryness and pain upon intercourse is a more common problem for women than yeast or bladder infections? Four out of five women are living with uncomfortable itching, irritation, and “vaginal atrophy,” which is the thinning and inflammation of vaginal tissue caused by too little natural lubrication. That lack of moisture happens when a woman’s estrogen levels fall too low.
Although there are many causes for decreased estrogen and the feminine dryness that inevitably follows, menopause is the most common cause. During peri-menopause (years when a woman’s period become irregular) and definitely after menopause (when a woman has not had a period for 12 consecutive months), estrogen drops dramatically. By age 50, virtually all women are living with at least noticeable and sometimes painful vaginal dryness.
Other reasons for vaginal dryness include frequent douching, birth control pills and even eating disorders. By age 40, more than half of all women are experiencing irritating dryness. Approximately 35% of all women under 30 say that they also live with uncomfortable dryness and pain during intercourse.
Dyspareunia
The word dyspareunia is a general medical term referring to painful sex. During peri-menopause, lower 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 called vulvovaginal atrophy. Vaginal secretions are reduced, resulting in decreased lubrication. The vagina also may shorten and become tighter at the opening. In some women this can lead to a feeling of vaginal tightness during sex along with pain, burning, or soreness. Reduced levels of estrogen also result in an increase in vaginal pH. This makes the vagina less acidic, which makes the environment more vulnerable to infections like yeast.
Inflammation of the vagina after menopause is called “atropic vaginitis.” This condition can include vaginal redness and discharge. This is associated with the loss of estrogen after menopause or it can be caused by a yeast or bacterial infection or even by irritation from soaps or hygiene products. The inflammation and irritation can lead to greater discomfort and sometimes tearing and bleeding of tissue with any penetration of the vagina.
Treatment Options
There are both non-prescription and prescription treatment options for vaginal atrophy. Moisturizers and lubricants can help if you have mild symptoms. Vaginal moisturizers like Replens gel can help but don’t have very long-lasting effects, and studies on the use of Replens have been less than ideal. Many patients have been concerned about using Replens due to the preservatives (methylparabens) and hydrogenated palm oil. However, if you have moderate or severe symptoms, estrogen replacement may be a better option. Hormone testing for baseline hormones is highly recommended to see where your hormone levels are and to better identify the deficiencies in order to help restore your hormone balance. Blood, saliva, and urine testing for hormones are some viable options.
There are topical and systemic types of estrogen replacement therapies. Topical (vaginal) estrogen is applied to the surface of the vagina. There are standard products such as Estrace® and Premarin® vaginal creams. Estrace® is a brand name estradiol cream that can run anywhere from $270-$350 cash since insurance companies do not often cover brand name products. Premarin® cream contains conjugated estrogen from equilin (horse) hormones and runs around $320-$360 a month with their coupon cards.
Compounded bioidentical creams are a less expensive alternative that can be customized according to individual need versus a standard commercially available dose. At our pharmacy, we can compound an affordable estriol vaginal cream indicated for vaginal dryness and its associated symptoms. Like estradiol, estriol is a form of estrogen. However, it has a higher affinity for vaginal tissue (estrogen binds to receptors more strongly). Estriol also does not convert to estrone (the type of estrogen believed to be linked to increased risks of cancer) so it can be argued that it has an even lower chance of causing some of the negative side effects associated with estrogens. Furthermore, other hormones such as progesterone and testosterone can be added to the estriol cream depending on the needs of each individual woman. There are often other fluctuating hormones that play a role in vaginal dryness. Because every woman is unique in her chemical makeup, customizing therapy based on individual need makes sense.
Topical Estrogen
Studies have shown that topical estrogen is the most effective treatment. Unlike non-prescription treatments, vaginal estrogen also helps reduce UTIs (Urinary Tract Infection) and overactive bladder. Also, topical treatment doesn’t have the health risks of systemic estrogen because only small amounts of estrogen reach the bloodstream.
Systemic estrogen is taken as a pill, patch, gel, or spray. Systemic estrogens affect the whole body. When given alone for an extended period of time, they can bring on unwanted long-term risks such as blood clots and cardiovascular disease. Recently, there’s been a new drug approved by the FDA called ospemifene (Osphena®) that treats moderate to severe dyspareunia in women who have problems with vaginal lubrication. Ospemifene is similar to drugs like Tamoxifen (used to treat or prevent breast cancer) and Evista (used to treat osteoporosis and reduce breast cancer diagnosis) and acts like estrogen on the vaginal lining. Drawbacks are that the drug is expensive ($200 per month) and has potential risks for DVT (blood clot), stroke, and hot flashes.
There are also non-hormonal compounded vaginal creams for women with a history of cancer where hormone therapy is contraindicated and it would not be appropriate to initiate an estrogen cream to treat vaginal dryness. There are non-hormonal options that can help to form an extracellular water film that moisturizes the skin, maintaining a water balance that aids in skin elasticity. There are also compounding options that can facilitate the healing process and tissue regeneration through their antioxidant and anti-inflammatory properties.
Sexual intimacy shouldn’t hurt. If you are suffering needlessly or are too embarrassed to address it with your doctor or husband, come by and talk to us. There is help so you can get your relationship health back again.
