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.
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.”
Trouble 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.
You say you’ve had painful intercourse for a few years, and were hoping it would pass. You tend not to want to have sex because the perception of pain outweighs the perception of pleasure. No surprise! And you’re not at all alone, for whatever comfort that gives you.
Once a woman transitions through menopause, she will be postmenopausal for the rest of her life. That means there is no source of estrogen, which results in what we call chronic and progressive vaginal atrophy. The effects of this are increasing vaginal dryness and thinning and narrowing of the vagina. This is not something that will reverse itself over time; without treatment, it only progresses. (I know! This is not something our mothers prepared us to expect!)
The majority of postmenopausal women who want to continue to have intercourse need to compensate for the loss of estrogen. The Premarin vaginal cream you refer to using is one option for treatment; it’s a long-term treatment, not a “cure.” It replaces the estrogen your body used to produce, directly in the area where it can have positive effect. This localized hormone treatment is preferred for women whose only issue is painful intercourse. There are fewer risks associated with it than with systemic hormone therapy (called HT or HRT, for hormone replacement therapy), which introduces hormones to more systems in your body.
If your painful intercourse isn’t adequately treated with the Premarin cream, there may be a secondary cause of pain, like vaginismus or vulvodynia. It is important to give feedback to your health care provider to be sure that the sources of pain are properly identified and treated.
It may be that your tissues are now healthy, but because you’ve avoided intercourse you could now benefit from vaginal dilators. Regular use of dilators will gradually stretch your vaginal tissues so that intercourse is comfortable again.
Alas, the sexual enjoyment that came so easily, with so little effort, is now a different story. But I hope you find the efforts of regaining sexual comfort worth the time and energy! I’m privileged to hear from patients about their successes, so I know it can happen!
You say you have not been sexually active for several years, and that recently a Pap test was painful to endure. Your doctor diagnosed vaginal atrophy. For reasons of your own health history and your family’s, you’re reluctant to use HRT (systemic hormone replacement, now called HT for hormone therapy).
Vaginal atrophy is a condition we characterize as chronic and progressive. It will not improve on its own and will get more uncomfortable over time. Initiating treatment sooner than later is usually advisable. Many treatments (like vaginal moisturizers) that maintain vaginal health are not effective at restoring vaginal tissues.
If you want to try a vaginal moisturizer as a first step, I’d recommend Lubrigyn Cream as a good option. It contains hyaluronic acid and elastin to maintain and support the tissue structure. We have other options in our shop if you’d like to experiment.
Localized estrogen--applied vaginally--is among the most effective ways to restore the integrity of an atrophic vulva/vagina. I do understand your hesitation about systemic hormones, but localized hormones don’t carry the same risk factors (it’s an option for breast cancer survivors, for example). And if your only menopause symptom is vulva/vagina-related then a localized treatment option is usually a great choice.
Osphena, a non-estrogen oral, daily treatment, is another prescription option that has been effective for my patients in restoring vaginal comfort. Here’s a blog post I published when it was first approved, and I’ve been using it successfully in my practice since.
You also asked about the MonaLisa Touch treatment, which uses laser treatment to stimulate the vagina to make collagen and develop a new layer of vaginal tissue. I don’t have direct personal experience with it, but have investigated it for my practice and find the research compelling. Pain and side effects are minimal, and the treatment appears to provide relief to 85 to 90 percent of women who have it. Definitely worth discussing with your health care provider!
Your age seems to be young to consider never experiencing a normal sex life again! (I admit that my threshold for expectation rises with my own age, but more treatment options are available each year.) With some effort, I’m quite certain you can revive that part of your life.
I think the Prevaleaf products are likely a good option for you. The Oasis Natural Daily Vaginal Moisturizer is paraben- and fragrance-free, as well as pH-balanced for the vaginal environment. Regular use is key to healthy tissues, which typically means less irritation.
Because you mention burning sensations after application, you might also like Soothe Natural Vaginal Soothing Cream. Like the moisturizer, it’s made with natural ingredients; it’s formulated for rapid absorption.
Your complaint of burning suggests the possibility of vulvodynia, a condition that results in burning pain with intercourse; anything that comes in contact with the area (near the opening of the vagina) can be experienced as burning or irritating. A careful pelvic exam can help determine if you have “simple” vaginal (or “urogenital”) atrophy or vulvodynia. If the former, the Prevaleaf products should be helpful and well-tolerated; other options might be explored if it’s the latter.
You say you find your partner attractive, you have a good relationship, and your gynecologist gives you a clean bill of health. And yet, you’re having trouble getting aroused.
One consideration may be Stronvivo, a nutritional supplement that has been shown to improve sexual function for women (and men), including improved libido/desire and ability to arouse and orgasm.
Some women with libido concerns benefit from supplementing testosterone. This requires an assessment and monitoring from your physician or nurse practitioner, since it’s prescription only. Use of testosterone in women is considered “off label”, or non-FDA approved, and not all practitioners are willing to prescribe it for their patients.
At the same time, you say you’re experiencing less moisture. This is critical to address, because painful intercourse is, of course, not an incentive to desire! There are varieties of lubricants that can add playfulness as well as immediate increased comfort; regular use of a vaginal moisturizer can help you through perimenopause.
I do know this issue can test relationships, and wish you the very best in finding a way forward! Be assured it’s possible.
There may be a Santa Claus after all, Virginia.
Of all the menopausal afflictions, vaginal dryness (or genitourinary syndrome of menopause—GSM—in medicalese) is the most pervasive. Virtually all of us will experience GSM to one degree or another, either due to menopause, hysterectomy, breast cancer, or some other hormone-disrupting event. Some of us will suffer from GSM to such an extent that sex or even a gynecological exam is impossible.
Yes, lubes and creams help. Estrogen replacement helps a lot, but not all women can or want to use hormones (especially if they’re breast cancer survivors, although localized estrogen has been confirmed safe). And there’s Osphena, a new nonhormonal drug that has proven effective. Still, nothing beats that firm, moist tissue we took for granted at 30.
Enter the MonaLisa Touch. With a name like that, you might hazard a guess that it was developed in Italy, and you’d be right. (I’ll never view that enigmatic smile in the same way again.) The procedure has been available in Europe and South America for a while and was recently approved for use in the US by the Food and Drug Administration.
The MonaLisa Touch is the same type of laser abrasion used to rejuvenate facial skin but repurposed for vaginal tissue. (This should not be equated with cosmetic surgery, however.) It’s a laser treatment that creates small lesions and removes a surface layer of dry vaginal cells. This causes the vagina to make collagen and stimulates the mucus membranes. A new, moist, healthy layer of tissue then develops.
Voilá! A 30-year-old vagina.
Wait a minute, I can hear you say: What about side effects? What about risks? Is this procedure appropriate for everyone?
Well, that’s the thing. The procedure appears to be safe and appropriate for women suffering from GSM, painful sex, mild urinary incontinence, and/or frequent urinary tract infections. Pain and side effects are slight—maybe one or two days of redness or soreness. It’s an outpatient procedure done with no or very little anesthetic. Results have been promising with 85 to 90 percent of women experiencing relief, sometimes almost immediately and sometimes significantly. “This is as close to the best result a medical treatment can achieve,” says Dr. Cynthia Krause, ob/gyn and assistant professor at the Icahn School of Medicine in New York City.
The procedure is straightforward, involving three laser treatments performed at six-week intervals. While many women experience relief quickly, the full effect may take up to six weeks after the final treatment. Laser treatment of vulvar and external vaginal tissue may also help with urinary incontinence and UTIs. Following that, an annual “touchup” may be required.
So, what’s the catch?
Well, for one thing, the procedure is new. While short-term studies are very positive, long-term data on side-effects or efficacy simply isn’t available. For another, it’s the cash. Since the procedure is new, most insurance companies won’t cover it, although that may change as the treatment becomes more mainstream. Cost varies depending on the region, but ranges from around $1500 to almost $2000 for the three required treatments.
Still, many women are thrilled with the chance to enjoy pain-free sex with their honey again, not to mention the freedom from a painful, burning, itching bottom. Like any treatment, however, there are no guarantees. Not every woman experiences the same result.
Still, for many women who suffer from the sexual difficulties and pain of GSM, the MonaLisa Touch is definitely worth looking into.
This is the sixth post in our occasional series inspired by the results of a survey we co-sponsored with PrevaLeaf, makers of natural products for intimate wellness. You can read our first post here, and catch up from there: You spoke. We’re listening.
Years ago, after the birth of her first child, a friend’s daughter challenged her mom, “Why didn’t you tell me all this stuff was going to happen?” The “stuff”my friend’s daughter was referring to were the very natural and often enduring effects of childbirth: hemorrhoids, incontinence, stretch marks, weak abs. You know, the insults we learned to live with long ago.
Preparing her daughter for these commonplace but distressing changes never occurred to my friend. She’d forgotten the shock she had felt when she looked at her own ravaged body after the birth of her first child… because life goes on.
I mention this because a couple of your comments in our survey about vaginal dryness reminded me of this incident:
I am all about health, nutrition, and exercise, so menopausal symptoms were not too severe—until the vaginal dryness. That came as a surprise, and I am still a little bit angry about that. Sex is supposed to be playful, fun and a stress release... not this much work to keep things going.
When vaginal secretions dried up I felt betrayed. Creams help but are no cure-all. I was not prepared for loss of libido. I naively thought retirement would be a chance to catch up from all of the missed sex due to overwork and exhaustion. Now I have the time but not the interest. Cruel trick.
These respondents are right on both counts: sex during (and after) menopause should be playful, fun, a stress-reliever. Something that you finally have time for. But loss of libido and vaginal dryness are some of the most common effects of menopause, and they very effectively suck the joy right out of sex. Maybe a cruel trick, yes, but also totally normal. To be expected. And, like the effects of childbirth, effects we can learn to work around. If we know about them and can prepare.
I’m thinking that if “someone” had told us what to expect, sexually speaking, during menopause, maybe there would be less shock, dismay, disappointment, and frustration. I’m not sure who that “someone” should be—mothers, older sisters, friends? But certainly it’s time for a greater cultural awareness and openness for straight talk about sex after menopause. (Well, at all stages, really.)
Which brings me to another comment from our survey:
I am 71 years old, married 44 years. I was told practically nothing about sex. My mom did not talk about getting older, and I am sorry because I am finding out things I could have known to expect, like dryness, hair loss, the need to cultivate intimacy. Our daughter is 42 and has never been comfortable mentioning women's issues so I just tell stories about what my mom did, how I interpreted that, and how I experience it now. Hopefully she will have some thoughts about what to expect.
Every woman experiences menopause uniquely. The effects can creep up gradually and may last for a long time—the rest of your sexual life, in the case of vaginal dryness. So it’s hard to prepare for exactly how you will experience “the change,” just as you couldn’t prepare, exactly, for how you would experience childbirth. But for childbirth, at least, you probably read books and attended classes to learn as much as you could. Shouldn’t we do the same for menopause?
For each of the life passages unique to women, there is a well-trodden path to mark the journey. And in the case of menopause, it’s clearly one that women need to know more about ahead of time.
We need to tell our friends and daughters the stories.
This is the fifth post in our occasional series inspired by the results of a survey we co-sponsored with PrevaLeaf, makers of natural products for intimate wellness. You can read our first post here and browse back to this one from there: You spoke. We’re listening.
We’ve already established that the women who took our survey tend to talk openly and regularly with their doctors and partners about their issues with vaginal dryness (and, presumably, about other menopausal symptoms as well).
This is excellent!
But I was puzzled by your responses to one of the survey questions. Over half (54.55 percent) of you never talk with your girlfriends about your desert vagina, and again, presumably, you don’t talk with them about other sexual menopausal issues, either.
I understand that it’s embarrassing to talk about vaginal dryness, but I’m sure you discuss other embarrassing menopausal topics with your BFFs, right? Maybe you joke about hot flashes and weight gain and mood swings and insomnia. Why avoid very common yet troubling sexual problems?
After all, who else (besides Mom) would really understand what you’re going through? Much as your spouse may want to be loving and supportive, it’s hard to really walk a mile in your menopausal shoes without being on the same biological journey.
So, why aren’t we talking? Why do we continue to soldier on in silence? Isn’t it time to reach out to the sisterhood? “Create a support network to sustain you through the experience,” writes Ellen Dolgen, author of Menopause Mondays: the Girlfriends’ Guide to Surviving and Thriving During Perimenopause and Menopause. “From my experience the menopause support I received from close friends has been invaluable.”
Amen to that, Sister!
I don’t mean complaining (although some griping is in order), or a revisiting of old wives’ tales and menopausal home remedies. I mean creating an emotional space in which we feel safe to talk about what we’re experiencing, whether it’s a bone-dry vagina or hair-trigger emotions, either of which may be wreaking havoc on our intimate relationships. And then to share credible information and to seek solutions.
In the interest of jump-starting some good BFF conversation, here are a few ideas:
Breaking the shroud of silence surrounding the sexual issues of menopause empowers us to seek and share solutions. Along the way, we discover that a lot of other women are in the same boat. The message is the same, isn’t it? You are not alone.
This is the third post in our occasional series inspired by the results of a survey we co-sponsored with PrevaLeaf, makers of natural products for intimate wellness. You can read our first post and the second, too: You spoke. We’re listening.
Those of you who responded to our survey are a chatty bunch! I’m thinking that, if you’re visiting the Prevaleaf and MiddlesexMD websites, you’re probably looking for information about sex and menopause. Ergo, you’re probably informed and willing to talk about it.
In our survey, we asked four questions about who you talk to regarding sexual problems, such as vaginal dryness: Do you talk to your doctor? To your friends? To your significant other? And how comfortable are you about discussing the issue, seeing as it’s not dinner-party banter?
In our sample of just over 100 women:
Compared to national surveys, you guys knock it out of the park!
Normally, women just don’t talk about problems like vaginal dryness, even when it seriously impacts their sex lives. In a recent study of 3,000 women ages 45 to 75, Dr. Sheryl Kingsberg, chief of behavioral medicine at University Hospitals Case Medical Center in Cleveland, reports that although 60 percent suffer from vaginal dryness, only 44 percent mentioned it to their doctors.
The same study found that, while half the women expected their doctors to broach the topic, only 13 percent of them did. “There is a tremendous lack of communication around vaginal dryness,” says Kingsberg in a recent AARP article. It’s “underdiagnosed and undertreated.”
That lack of communication may result from embarrassment and timidity on both sides about bringing up a sensitive personal issue, but Kingsberg speculates that it comes from ignorance as well.
In Kingsberg’s study, 24 percent of women didn’t know that their vaginal symptoms were related to menopause. We all do a lot of girlfriend talk about hot flashes, night sweats, and mood swings. Vaginal dryness? Not so much. Fair enough, then, that it comes as a surprise and that we don’t automatically associate it with menopausal changes.
All of which sometimes leads women to home remedies and desperation measures for relief.
In a small study last year of 141 women by the University of California at Los Angeles, 17 percent used petroleum jelly and 13 percent used various oils as a vaginal lubricant, resulting in far higher levels of yeast and bacterial infections than for women who used lubricants made for vaginal use.
That’s because the microbial environment in the vagina is finely balanced to fight infection. Mess with that by using products that upset that balance (vinegar douches, saliva, oils), and you’ve got trouble.
“I have always been fascinated by the vast array of commercially available over-the-counter products marketed to women to modify their vaginal environment,” Joelle Brown, lead researcher in the UCLA study told Reuters Health by email. “In most pharmacies you can find entire aisles dedicated to vaginal douches, suppositories, and gels that are meant to make your vagina smell like a tropical splash or a cookie.” Here in my small Midwestern city, there are 15 moisturizers or lubricants on the shelf at Rite-Aid, 38 at Walgreens. Are we willing to stand there long enough to figure out which are healthy and helpful for us at midlife?
I may be preaching to the choir here, ladies, given your amazing survey result, but we need to start talking about our bottoms. To our doctors. To our partners. And to our friends.
I’m thinking that some good, informed conversation among girlfriends might help to shed light on this common yet misunderstood problem. And if you have any questions or unresolved issues, don’t wait for your doctor to bring it up. You may have to start the conversation yourself.
This is the second post in our occasional survey inspired by the results of a survey we co-sponsored with PrevaLeaf, makers of natural products for intimate wellness. You can read our first post here: You spoke. We’re listening.
Almost every day, I see patients who suffer, and I mean suffer, from vaginal dryness due to menopause or surgically induced menopause, such as hysterectomy. In medical parlance, the umbrella term for vaginal pain is dyspareunia, and the term for dry, brittle vaginal tissue is now “genitourinary syndrome of menopause," just so you know (it’s been called vulvovaginal atrophy until recently).
If a patient comes to me, that usually means the condition is painful and probably damaging her sex life, and thus, her intimate relationship. It’s hard to relax and enjoy sex when it hurts, and sex is an important glue that binds a couple.
The first thing you need to know about vaginal dryness is that it is almost always treatable! You don’t have to suffer; sex doesn’t have to be painful. And you can take that to the bank.
The second thing you need to know is that you may need patience and persistence in seeking a treatment that works for you. You may need to persist until you find a practitioner who won’t tell you it’s all in your head and is willing to work with you to find a solution. (We call that person a sexually literate healthcare provider.)
As one survey respondent wrote: “I experienced severe vaginal dryness after going through chemotherapy for breast cancer at the age of 44. The first two doctors I visited could not tell me that I had vaginal dryness. Third time’s the charm! I saw a nurse practitioner who dealt with the issue. She was able to tell me what was going on and how to treat it.”
And you’ll still need to be persistent while you try out treatments until you find one that works for you. That can take some experimentation—three months is commonly how long it takes to thoroughly test-drive a treatment regimen. It’s inconvenient, but if you’re willing to persist, chances are you’ll experience pain-free sex again.
Generally, it makes sense to start with the easiest, most natural regimen first. Take care of your bottom by avoiding scents, harsh soaps, douches, non-breathable underwear. Then, use lubricants liberally during sex and use a moisturizer regularly. Natural and high-quality, of course.
If this vaginal-care regimen doesn’t do the trick, another option is topical estrogen. Many women are hesitant to use a hormonal product, but the recent report from the American College of Obstetricians and Gynecologists (ACOG) reaffirms that estrogen used topically in the vagina can offer significant relief without being absorbed systemically. So it’s safe for breast-cancer survivors.
Another option is the new drug Osphena, which acts like estrogen--without being an estrogen--to vaginal tissue; it has no effect on other tissues, such as the breast. (This is called an estrogen agonist/antagonist.) So it’s also safe for those with breast cancer risks. It is a once-daily pill, however, and does have side effects that need to be taken into consideration.
Finally, an important way to keep vaginal tissue healthy is sex itself! Once you can tolerate a little sex, you’re on the way to enjoying a lot more.
Be of good faith, sisters. Many problems in life are tough to solve. Vaginal dryness isn’t one of them.