In a sense, the most “natural” replacement for lost estrogen is estrogen, which is a prescription product (like Premarin or Estrace vaginal cream, Estring, Vagifem, or the non-estrogen Osphena).
If, for a number of reasons, you prefer not to take that path, the next-best option is to maintain vaginal tissues by using a moisturizer regularly, two to three times a week. Moisturizers are designed to bring more moisture--no surprise--into the vagina to prevent the progressive dryness that occurs in menopause with the absence of estrogen.
One more option might be an oral nutritional supplement, Stronvivo, which some research shows improves vaginal moisture. It does this by improving blood flow, and that circulation also supports tissue health.
You say that your wife suffers from lichen sclerosus, a condition that creates skin tissue that is thinner than usual (and is a higher risk for postmenopausal women). Warming oils and lubricants, unfortunately, create discomfort rather than arousal for her. I'm not aware of an option in that category that would work for her, since the ingredients that make them effective--usually something minty or peppery--will almost certainly cause an adverse reaction.
Plain lubricants won't cause that reaction; those we include in our product collection should be well-tolerated by lichen sclerosus patients.
There are a couple of other options you and your wife could explore for arousal. The use of testosterone has been beneficial for 50 to 60 percent of the women in my practice who've tried it. Testosterone is by prescription and off-label for women, which means a discussion with her health care provider is required.
Other prescription options include localized estrogen, Osphena, or Intrarosa (a recently available FDA-approved choice). Any of these would increase blood supply by "estrogenizing" the genitals, which can improve arousal and orgasm as well.
Congratulations on undertaking this exploration together! Good communication and mutual support are so important to shared intimacy.
Before we begin, I just want to reiterate our long-held position here at MiddlesexMD: Natural is always better. By that I mean, if you can ease vaginal pain and enjoy sex comfortably using non-hormonal products like moisturizers and lubricants, that is always the first and best option.
That is also the position taken in a new report issued two weeks ago by the American College of Obstetricians and Gynecologists (ACOG). But when the non-hormonal route just doesn’t cut it, when the pain of vaginal dryness and atrophy is unpleasant enough to interfere with life and good things like sex, then the ACOG committee says that topical estrogen treatment is a good option even for breast cancer survivors. (Check out this link on our website for tons more information.)
Let’s dig into this.
For a long time, doctors focused on simply helping women with breast cancer to survive. Now, the good news is that women who have had breast cancer are indeed surviving for years longer. So the focus has shifted to quality of life—like making sure that sex is comfortable, for example.
This can be tricky, because we all know that estrogen is a bad thing for breast cancer survivors. In fact, a type of breast cancer, called “estrogen-receptor positive,” which unhappily is more common in postmenopausal women, has special receptors that are sensitive to estrogen. With this type of cancer, estrogen acts like fuel, making the cells grow more quickly. That’s why ongoing treatment for women who have had this type of cancer includes Tamoxifen or “aromatase inhibitors” that block estrogen activity.
Problem is, of course, estrogen is a good thing for our vagina, among other parts, and a lack of estrogen wreaks havoc on that sensitive system. Thus, drugs that block estrogen activity also cause urinary tract infections and painful vaginal dryness and atrophy. These side-effects can be so severe that 20 percent of women simply stop taking the drugs.
We know that oral estrogen replacement therapy—taking estrogen pills—increases systemic estrogen levels, but what about localized estrogen that’s used externally to treat vaginal dryness and atrophy? Does that increase estrogen levels in the body? Does it increase the risk of relapse?
While there hasn’t been a lot of research on the subject, ACOG released its committee report early in February stating: “Data do not show an increased risk of cancer recurrence among women currently undergoing treatment for breast cancer or those with a personal history of breast cancer who use vaginal estrogen to relieve urogenital symptoms.”
The ACOG guidelines recommend using the lowest effective dose for as little time as possible. And while the hormone comes in three forms: cream, ring, and a vaginal tablet, the lowest rates of absorption and the most accurate dosages occur with the ring and tablet.
For women whose symptoms are severe and who aren’t sufficiently relieved just by vaginal moisturizers and lubricants, it’s nice to know that there are other options. If you’re a breast cancer survivor who is suffering from vaginal dryness and painful sex, it’s time for a sit-down with your doctor to discuss treatment options. It’s time to start living well again.
One of the joys of the work I do is hearing from women about how what I do—through my practice or MiddlesexMD—helps them with their health and intimacy. Often, I hear those stories in conversations, and as good as my intentions are (because I believe in sharing our stories), by the time I get back to my office, I forget to take good notes. But a letter! Remember how lovely it is to get letters? Here’s one I can share with you!
Dear Dr. Barb,
I loved your blog post “Don’t be a Stranger.”
It was timely for me. I thought I was doing this all pretty well. Three years ago when my primary care doctor retired, I chose my new provider carefully. I told her I’d been following MiddlesexMD since the blog launched in 2010, and that I was interested in keeping my sex life healthy. I asked her not to shy away from anything she thought I should know, and that I intended to try to be as proactive as I could be.
It was a good start. I’m relatively healthy, so I have seen her only on an annual basis since. I have vibrators and dilators and use moisturizers. Most important, I have a good partner!
And life went on. My husband travels a lot. My father died. I went on Medicare (which somehow managed to administratively change my primary care provider – requiring 8 phone calls and numerous interruptions). Job changes and financial stresses complicated my life.
At my visit in January (before your blog post), my doctor and I worked to figure out how to make sure my medical care didn’t get disrupted. We reviewed all of my “checkpoints” – mammogram (sister is a breast cancer survivor), pap test (I’ve had cervical “pre-cancer”), bone density, skin check, high cholesterol testing, blood screens, etc., etc.
Only when I thought the exam was about to end, did I blurt out, “I’m unhappy with my sex life.” So much for proactive.
To her credit, she stopped. And she started asking me questions. After a little exploration, she asked, “Have you ever tried topical estrogen?”
I had. But not for years.
After a little examination (serious atrophy) she prescribed a cream.
Three weeks later, my sex life had taken a new (and better) trajectory.
So, I want to echo your advice to keep the conversation going – because I can’t keep it in perspective by myself, no matter how good my intentions are!
You say a prescription for estrogen seemed to increase your libido at first, but that effect has diminished. No, you haven't become immune to estrogen. Unfortunately, libido is a bigger and more complicated issue than just one hormone. Many women don't find any improvement in libido with estrogen; I tell patients it certainly won't make it worse, and it may make it somewhat better. And it's not uncommon for the initial effect perceived from a new treatment to wane over time.
You also ask whether where you apply the estrogen cream makes a difference to its effect on your libido. The medical answer is that because its effect depends on its entering the blood stream, it can be applied to skin anywhere it is likely to be absorbed. If you have pain with intercourse or dryness because of menopause, applying the cream to genital tissues may help, but that's a different issue than libido.
Women's libido is complicated (several hormones and numerous neurotransmitters in the brain are involved, as well as emotional and psychological factors), and the treatment options for low libido are currently limited. We offer a number of suggestions on our website, but I also encourage women to talk frankly with a menopause care specialist.
You say you've completed five years of regular tamoxifen, and your doctor has suggested Vagifem 10 mcg to address symptoms of dryness and itchiness. Vagifem 10 mcg is a very, very tiny dose of bioidentical estrogen, delivered as a tablet to dissolve in the vagina. I have many, many breast cancer patients who use it or other "localized estrogen" or "vaginal estrogen" options. Like you, they've had significant issues without it; over the counter creams, lubricants, and moisturizers may have had some benefit, but over time they've not done enough.
From what we know, localized estrogen doesn't enter the blood stream and get disseminated throughout your system; it is absorbed only in the genital area where it's needed. I like Vagifem because the dose is very low and there appears to be consistent absorption. But it is still estrogen, and there is sometimes reluctance to add this to a woman's regimen, especially after breast cancer.
There is a new non-estrogen treatment option for this condition. Called Osphena, it is a SERM (Selective Estrogen Receptor Modulator), the same class of medication as tamoxifen. They both target tissue and affect estrogen activity: tamoxifen targets breasts to block; Osphena targets the vagina to activate. Osphena is oral, daily, and in my practice has been well tolerated and effective. While it's been on the market for two years or so, it has not specifically been trialed in breast cancer patients (and nor have other medications, a reality I hope will change—and soon). There's not yet data on safety for women like you, but other SERMs on the market are favorable for breast health, it makes sense to think this one may be, too.
We don't have all the answers yet, unfortunately! Ultimately, the decision comes down to quality of life for you, and I'm glad it sounds like you have a health care provider who is helping you consider your options.
You ask whether there's an over-the-counter hormonal cream to restore vaginal elasticity. You're finding intercourse painful and experiencing dryness.
Vaginal moisturizers will help to retain some moisture, but none of them will reverse the process—which is, medically speaking, atrophy given the loss of estrogen. The combination of moisturizers and lubricants will keep things comfortable for a while, but most women eventually need more.
Localized estrogen or the new pharmaceutical Osphena are effective; either requires a consultation with your health care provider. I'm not aware of any hormone-based medication available over the counter and, in fact, encourage a consideration of your medical history and current factors before use.
The dryness, discomfort, and frequent infections you describe are consistent with vulvovaginal atrophy (now sometimes called "genitourinary syndrome of menopause") and, possibly, vulvodynia. The mainstay of treatment for these conditions is to "estrogenize"--add estrogen to--the vagina.
It was once thought that all estrogen posed some vascular risk, so I understand the hesitation about continued use for you after a blood clot. More recently, though, localized (placed directly in the vagina rather than taken orally) estrogen has been shown not to raise the risk of thrombosis. Estrogen products still carry the "black box warning," regardless of the method of administration. About a month ago, though, additional data were presented to the FDA asking them to remove that "class labeling," since the means of administering makes such a difference. We'll see what happens, but you can ask your health care provider to reconsider.
In addition to continuing the use of a vaginal moisturizer, you might also use a silicone lubricant (Pink is a favorite at MiddlesexMD). That type of lubricant reduces friction and gives more glide or slipperiness. And you could ask your health care provider to prescribe a topical xylocaine, an anesthetic that you can apply to the area to make you more comfortable during and after intercourse.
Have another discussion with your health care provider, and try all your options! Comfortable sex is possible for you.
What you describe—pain and a burning sensation around your clitoris—is most consistent with vulvovaginal atrophy. As we lose estrogen, the genital tissues thin, and the labia and clitoris actually become smaller. There's also less blood supply to the genitals. Beyond making arousal and orgasm more difficult to achieve, these changes can also lead to discomfort, and experiencing pain when you're looking for pleasure will certainly affect your sex drive and arousal!
Localized estrogen is the option that works best (and it's often a huge difference) for most of my patients, restoring tissues and comfort. Talk to your health care provider about the available options and what you might consider in choosing one.
A vaginal moisturizer can also help you restore those tissues, but I suspect you'll find that most effective in combination with localized estrogen.
Please do take steps to address your symptoms! If sex can be more comfortable and enjoyable for you, I'm hopeful that your sex drive will rebound.
Localized estrogen is not thought to be absorbed systemically, which means that blood estrogen levels remain in the menopausal range; if there is any absorption, it is scant. At that level, it does not increase risks of breast cancer. Unfortunately, the "prescribing information" (PI) for localized hormones is required to be the same as for all estrogens, although the risks are significantly different from those of systemic estrogens.
Last month, I attended the North American Menopause Society (NAMS) annual meeting, where I heard that a request has been filed with the FDA to amend the PI to fit more accurately what's known about localized estrogen use.