News from NAMS: The Latest on Lubes and Moisturizers

For nigh onto 30 years, the North American Menopause Society has encouraged research into and disseminated information about all things menopause. It’s the hub of the wheel for healthcare professionals and individuals alike seeking the latest scientific information and objective advice about “the change.”

One presentation at this year’s annual meeting in October struck me as particularly apropos for MiddlesexMD readers—part refresher course; part new information. So I’d like to pass it along.

In a wide-ranging talk, Dr. Nick Panay, a gynecologist from Great Britain, explored current understanding of that most common and persistent problem of menopause: painful sex due to vaginal dryness. He reminded us that lots of women will suffer from it (about half of women at some point in life), and that many won’t mention it to their doctors. He encouraged healthcare workers to ask: “If you don’t ask, women often won’t volunteer the information.”

So far, so good, but ground that’s been covered.

Everyone likes sex better with good lubrication, he said, and women often expect their bodies to lubricate adequately, just like they did “before,” so when they inevitably don’t, it’s a real buzzkill for sex.

This state of affairs can be tackled in many ways—topical estrogen, Osphena, Intrarosa, and the good old stand-by, moisturizers and lubricants. According to Dr. Panay, moisturizers and lubes can provide relief from vaginal dryness, but they don’t address the underlying cause, which is loss of estrogen. Only estrogen can do that.  

Turns out, however, that a couple additional considerations might affect how your body reacts to a specific moisturizer and/or lubricant, depending on its ingredients. In this report, Dr. Panay mentions three physical characteristics of the vagina that might be altered by components in what we put there.

  • pH balance. A healthy vagina is slightly acidic with a pH value between 3.8 and 4.5. Ideally, whatever lubricant or moisturizer you use should be close to those values to retain the vagina’s protective bacterial balance.
  • Osmolality. This is a fancy concept that refers to the amount of particles dissolved in a liquid. High osmolality has a lot of “stuff;” low osmolality doesn’t. The way this works in the vagina is that, ideally, equilibrium is reached between vaginal cells and the moisturizer or lube, depending on its osmolality. When the osmolality is off-kilter, it either draws water from vaginal cells or over-moisturizes them, either of which could cause changes in the vagina. In a test of several products on slugs, for example (yes, like you see pictured below), which as we know are all about moisture and mucus, products that were hyper-osmolalic (high levels of particles) irritated the slugs a lot.
  • Additives. Ingredients like glycols, parabens, and preservatives, which are found in some products can also irritate the vaginal lining, kill good bacteria, and increase susceptibility to infection.

Ideally, says Dr. Panay, the lube/moisturizer you use should be as close to vaginal mucosa as possible—a product that is “optimally balanced in terms of both osmolality and pH and is physiologically most similar to natural vaginal secretions.”

slug like those used for testingTrouble is that the ingredients in a moisturizer or lubricant aren’t always listed on the label and identifying those with correct osmolality and pH levels is fairly impossible for the average user, especially since a product with a good pH level might have bad osmolality numbers. Dr. Panay shared the results for several dozen products available worldwide, and we were happy to see that YES VM, a moisturizer, and YES WB, a lubricant, both scored very well in the testing (we shouldn’t be too surprised, since they’re both very popular in our shop).

So what’s the practical application for all of this new data? For us at MiddlesexMD, we’ve got some new criteria for vetting and recommending products from our shop (sadly, Dr. Panay’s tests couldn’t include every product currently available). We hope that makers of moisturizers and lubricants will take these new findings into account in their formulations, and we can now ask for data on osmolality in addition to pH levels when we evaluate products.  

For you, keep in mind that lubes and moisturizers are the first line of attack in making sex comfortable (or possible) and in keeping vaginal tissue flexible and moisturized. According to Dr. Panay, this is true even if you use topical estrogen or another drug, such as Osphena or Intrarosa. Choose your products carefully, looking for high-quality products that are free of glycol, parabens, and other additives.

Pay attention to any increase in vaginal irritation or infections. Your lubricant or moisturizer could be contributing. Don't give up on lubes or moisturizers, though: Try another product or formulation that’s a better match for your pH and is providing the right amount of moisture to your tissues.

Q: Is there a “natural” replacement for Premarin?

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).

You asked. Dr. Barb answered.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.

Both Emerita and Prevaleaf Oasis are natural vaginal moisturizers.

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.

 

 

Q: Is my progress with dilators normal?

It sounds like you've done a great job with regular, sustained use of dilators to restore the vaginal opening. Be aware that the top of the vagina tapers a bit, so it's possible that the largest-diameter dilator, because of its width, just won't go in as far as the others. The only way to assess for certain what's happening is to have a pelvic exam with your health care provider; I'd explain to her or him that you've been using dilators and see whether s/he finds anything other than normal.

During intimacy with a partner, many women find that they can control the depth and angle of penetration more easily when they are on top. That seems to be a safer starting point for women who have reason to better understand what's most comfortable–and pleasurable.

Congratulations on taking care of yourself!

To ask your own question, use the "Let's Talk" button top and right on our website. You'll receive a confidential reply via email, and your question may be used as the basis for a Q&A post here on our blog. 

Q: Does my partner absorb any of my localized hormones?

Whether you're using a cream, tablet, or ring to add localized hormones to your vagina, your partner is not absorbing any—no more than he did when you were producing your own hormones before menopause. You (and he!) can feel perfectly confident about your use of these products, and your intimacy will benefit from the increased comfort you're likely to experience.

Q: Should I have my vaginal opening surgically enlarged?

If you can comfortably insert any size tampon, you don't need much more space to allow for intercourse. I use two fingertips as a rule of thumb; that is, if I can insert index and middle fingers during an exam, I can assume intercourse is likely to be comfortable. The only time I've done surgery to enlarge the vaginal opening was when only a Q-Tip could be inserted--a definitive intact hymen.

What you might find helpful is vaginal dilators to help to extend the elasticity that you already have. The graduated sizes of dilators, regularly used, can gently stretch the tissue to assure comfortable penetration. I'd certainly try that before opting for surgery!

Q: Is it possible that my vaginal dilators are too long?

Dilators are not intended to fit all the way inside your vagina. The extra length gives you some space to hold on to and to apply gentle upward pressure. The pressure gently stretches the tissues to achieve additional length or depth in your vagina.

The graduated diameters of the dilators in the set are intended to address narrowing of the vagina. Use the smallest one until it's comfortable, and then move to the next-larger size. We offer a more complete description of how to use dilators on our website.

I also encourage the consideration of vaginal moisturizers and localized estrogen to help keep the tissues healthier and more supple. That in combination with the dilators can give you more comfortable, faster, more lasting results.

Q: Could my partner's medications affect my vaginal discharge?

The odor and discharge that you describe sounds most consistent with bacterial vaginosis; it's not a result of your partner's medications. This infection is not serious or particularly worrisome, but the symptoms are certainly a major annoyance!

You could first try RepHresh, a product that may alleviate the symptoms by correcting the vaginal pH (you can read more about pH in this recent blog post). Vaginosis can also be treated with an antibiotic, administered orally or vaginally.

Douching is not helpful and can be harmful: It disrupts normal bacteria in the vagina and makes you more susceptible to infection.

Q: Could I be allergic to estrace cream?

Estrace, or estradiol, is an estrogen that was circulating in your bloodstream, produced by your ovaries, for 40 years or so! Any allergy is likely to be to the "vehicle," the substance that contains the estradiol as an active ingredient. I assume your reaction was local--in the area where you applied the cream.

An option that may work for you is Vagifem, a bioidentical estradiol in tablet form that you place in the vagina twice a week (usually after starting with daily use for 14 days). Vagifem comes with a very slim applicator to place it in the vagina.

Another choice might be Estring, another bioidentical estradiol in the form of a ring. The ring is placed in the vagina for 90 days and is then replaced.

Take the time to find an option that will work for you!

Q: Will dilators help me prepare, in my 60s, for my first sexual encounter?

Yes, vaginal dilators will help gently and gradually to assure that your vaginal tissues are stretched. I recommend using them one or two times a day for 20- or 30-minute sessions. The more you use them, the more quickly you'll get the results you're looking for.

Dilators come in graduated sizes, starting as small as a half-inch diameter and stepping up to 1 3/8-inch diameter. Take your time, and I'm sure your first experience will be a comfortable one! Congratulations.

The Vagina Dialogues: Treating Vulvovaginal Atrophy

Remember that play that premiered a few years back called, “The Vagina Monologues”? Well, I wish someone would write one called, “The Vagina Dialogues” so that women would start to realize that it’s okay to talk with their doctors about their vaginas!

As you know, menopause brings with it all kinds of changes to various body parts, including your vagina.  There’s a very common condition called vulvovaginal atrophy (referred to as VA in the medical world), in which the walls of the vagina become thin, dry, and possibly even inflamed due to a decline in estrogen. (The vulva refers to your external genital organs, including the labia and clitoris.)

Symptoms of vulvovaginal atrophy include:

  • Vaginal dryness, irritation, or burning
  • Burning and/or urgency with urination
  • Urinary tract infections
  • Urinary incontinence
  • Discomfort and/or light bleeding after intercourse

About half of all postmenopausal women will experience some symptoms of atrophy. But often they’ll look at these signs in isolation, not realizing that a urinary tract infection may be directly related to the discomfort they feel during intercourse—and that both might be indicative of vulvovaginal atrophy.

Although treatment is readily available, it has to be diagnosed first. But because women are often too embarrassed to talk with their doctors about vaginal problems, they don’t mention it during annual physicals, let alone pick up the phone when symptoms first concern them.

Instead, they try to treat it themselves, guessing at what might work, not knowing there’s a name for what they’re experiencing. And while over the counter lubricants may offer some short-term relief for dryness, vulvovaginal atrophy is chronic and requires ongoing treatment to address the underlying cause.

Typically, treatment for vulvovaginal atrophy involves some sort of estrogen therapy, in the form of a vaginal tablet or ring or topical cream. But the first step is getting a diagnosis. That’s why it’s so important to talk with your doctor about any changes you experience in your vaginal area.

So please: Don’t be shy and don’t wait. Be proactive and bold when it comes to taking charge of your own body. As with many other parts of life, it’s much easier to maintain healthy tissues and organs than to treat problems long after they’ve begun.

As soon as you feel anything unusual, lubricants don't seem to work as well, or you begin experiencing any of the symptoms listed above, make the call to your physician. And begin your own vagina dialogues, the sooner, the better.

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