Q: Will my libido be there when I find the right relationship?

You say you experienced “pins and needles” during intercourse in your last relationship, and of course it’s difficult to feel amorous when you’re expecting pain. That’s a common description of what it feels like to have genitourinary syndrome of menopause (also called vulvovaginal atrophy) or vulvodynia. A careful pelvic exam by a skilled practitioner can diagnose the condition.

There are treatments available, starting with moisturizers and including hormones, either local or systemic, and other medication options. But a clear diagnosis is the first step.

And then the relationship component. A strong and supportive relationship is an important part of libido and desire for most women. At midlife and beyond, though, we face the “use it or lose it” phenomenon: Here’s a blog post that addresses a “maintenance plan” so that when you find the relationship that’s worth it, you’re ready for intimacy.

Q: Are my bladder infections treatable with hormones?

You say you've had itchiness and dryness and get bladder infections fairly regularly. Those symptoms are completely consistent with the absence of circulating estrogen to the genitals. Until recently, this condition would have been called vulvovaginal atrophy; its current name, genitourinary symptom of menopause, does a better job of describing that it affects both the urinary system and the genitals.

Women have estrogen receptors throughout their bodies, but they're most concentrated in the vagina, vulva, and lower urinary tract. In the absence of estrogen, symptoms in that area are more notable. That's the bad news.

The good news is that there are steps we can take to keep our tissues healthy and vital. See our website's suggestions for vaginal comfort, and I encourage women to consider, with their menopause care providers, the use of localized hormones.

Q: Am I shrinking down there?

You've noted that your clitoris appears to be smaller, which is a normal part of aging. With the absence of estrogen, it's estimated that a woman loses 80 percent of her genital volume—unless there is some intervention. The two most effective ways to minimize this diminishment are to remain sexually active (that "use it or lose it" thing I've talked about before) and to use localized estrogen. Both help to maintain the integrity of the genital tissues.

Our intent is not to "prevent" menopause, because it's a normal part of our lives. With my patients, my aim is to mitigate enough of the symptoms of menopause to be able to maintain the sexual intimacy that's an important part of life for many of us.

More often than you'd think, a patient who thought she was "done with sex" comes to me for help when she enters a new relationship. It's possible to reverse some of the atrophy that happens naturally with inactivity, but it's more difficult than maintaining sexual health along the way. If a woman is certain that she has no interest in being sexually active, there's no negative health effect of the genital atrophy—beyond the loss of the positive health benefits of sex.

Q: Does a blood clot limit my treatment options?

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.

Q: Why do I have pain and hypersensitivity?

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.

Q: Why do I have a burning sensation?

A burning sensation in the vaginal and vulvar area can be a symptom of vulvovaginal atrophy, which occurs as estrogen levels decline. Premarin cream or other localized estrogen can reverse those atrophic changes; it typically takes weeks of use for full effect.

If the burning sensation is in or extends further back, toward or including the buttocks, it's likely not vulvovaginal atrophy. It could be, instead, a nerve condition. Shingles, unfortunately, can happen in this area; there are other pelvic floor conditions—like scarring or injury—that can affect nerves. A careful pelvic exam can help to determine exactly what's happening.

I encourage you to talk to your health care provider—and again, if you're not seeing improvement!

Q: Can I regain my sexuality 12 years after a hysterectomy?

The pain that you describe sounds like vulvovaginal atrophy, and possibly vulvodynia (vestibulodynia). These conditions can both be treated, but need the attention of a physician for an accurate diagnosis and treatment plan. Estriol and progesterone, which you say you're trying, aren't likely to be of great benefit to you, but localized estradiol is likely to help.

It's sad at any age to put this important aspect of a marriage aside. And, because, unfortunately, the longer it goes on, the worse these conditions get, I'd recommend a visit to your physician sooner than later. If you're unsure of your physician's ability to adequately manage this part of your health, find a Certified Menopausal Provider in your area.

In the meantime, make sure you are using a good lubricant; a silicone lube like Pink is probably going to be most effective for this condition. It's also important to use a vaginal moisturizer like Emerita.

I'm sure you feel discouraged. Know that I have had patients who have regained the sex lives they wanted! They've felt it was worth the effort. Good luck!

New VA Treatments in the Pipeline

Sometimes we medical people get to hear about medications and treatments before they hit the doctor’s offices and pharmacies. Recently, MiddlesexMD advisor Dr. Michael Krychman interviewed Dr. James Simon, a well-connected expert in women’s sexual health, about new treatments that are under development to treat vulvovaginal atrophy (VA).

If you recall, VA is the thinning and inflammation of your delicate genital tissues, including the vagina, which is caused by loss of estrogen after menopause. As you can imagine (or already know), it causes genital irritation, an increase in minor infections, and uncomfortable—or downright painful—sex.

VA doesn’t go away, and it doesn’t get better by itself—it requires treatment, usually in the form of estrogen, whether taken internally or applied topically. Topical estrogen creams, tablets, and rings can be very effective in treating the effects of VA.

But a few new approaches are also under investigation. They are:

  • DHEA suppositories. DHEA (which, if you must know, stands for dehydroepiandrosterone), is a steroid that, according to Dr. Simon, is “taken up by the vaginal cells themselves, which convert them to testosterone and estradiol.” The estradiol eases symptoms of VA, and the testosterone improves muscular function and makes the vagina and clitoris more sensitive, so it also gives the libido a little boost. None of it is absorbed into the system, so the medication should be safe for women with breast or ovarian cancers. Don’t expect to see this little number on pharma shelves too soon. Dr. Simon advises patience, since the treatment in still in clinical trials and then must be approved by the FDA.
  • Treatment for VA in pill form. Because many women (and their partners) find topical treatments for VA—creams, rings, suppositories—messy, unpleasant, and a sex inhibitor, a new drug that is readily absorbed by the estrogen receptors in the vagina, but not in other places, such as the endometrium, is being tested.
  • Very low-dose estrogen tablet. In an ongoing effort to find the lowest effective dose of estrogen, Novo Nordisk, the manufacturer of Vagifem, recently found that 10 micrograms is effective in treating symptoms of VA. “It seems to work extremely well, even at these extraordinarily low doses,” said Dr. Simon. And even after taking it for a year, he points out, this dosage amounts to just over 1 gram of estrogen, an amount that is probably safe even for breast cancer patients. The disadvantage, warns Dr. Simon, is that, while the medication treats vaginal symptons well, it might not be as effective for the vulva (the external genitalia). In this case, women may still need an estrogen cream for the very important vulvar care.
Since over 40 percent of post-menopausal women experience symptoms of VA, an effective treatment that doesn’t increase our cancer risks would make us—and our partners—very happy. Take heart. “Many companies are dedicated to innovative treatments without rise in systemic hormones,” said Dr. Krychman.