What is causing my vaginal discomfort?

Statistics show that less than half of menopausal women discuss problems with vaginal dryness and discomfort with their doctors.  For fairly obvious reasons this is a difficult conversation to initiate.  Since we were little girls we didn’t talk openly about our “private parts” and when we did we used code names (like the one my niece uses with her kids – “Va-jay-jay”).  Many women also seem to believe symptoms that develop “down there” are an inevitable part of aging and not much can be done – so why bother talking about it.  This is unfortunate because there are a number of options that can make those postmenopausal years much more comfortable.

So, why do we start having problems?  Around age 35, our testosterone level begins to fall.  Yes, testosterone!  This is the first blow because testosterone not only helps our libido, it plays a role in supporting the vaginal tissues.  Then, around age 45, the estrogen level starts to fluctuate and decline.  By the time we reach menopause it has dropped dramatically and this has a major impact not only on the vagina, but the vulva and the area around the opening of the bladder.

Without estrogen the vaginal cells change markedly in character.  They lose their stores of glycogen – the substance that turns into sugar, which feeds the lactobacilli (the “good bacteria”) that live in the vagina.  Healthy colonies of lactobacilli make lactic acid, which keep the vaginal secretions slightly acidic and help prevent an overgrowth of unwanted intruders from taking up residence in the vagina – such as yeast, E. coli, and other “bad bacteria” like the ones that cause a fishy odor.

In addition, the lack of estrogen causes the vaginal cells to shrink in size so the lining becomes very thin.  There are fewer mucous producing cells, which can lead to dryness.  The underlying connective tissue weakens making the vaginal wall less elastic and more susceptible to irritation.  All of this leads to discomfort, especially with intercourse, and predisposes women to infections.  Over time, the situation gets progressively worse and more uncomfortable.

So what can be done? Certainly using moisturizers like Replens and lubricants like K-Y jelly can help decrease the symptoms and make sex more pleasant.  But they don’t actually prevent the changes going on in the vaginal cells.  This can only be accomplished by providing an ongoing supply of estrogen.  Initiating treatment at the time of the menopausal transition keeps the vagina in its “youthful” healthy condition.  The oral or transdermal forms of estrogen, which are prescribed for hot flashes, work very effectively for most women.

The other option is to use a preparation designed to be inserted directly into the vagina.  These come in doses much lower than the standard formulations for other menopausal symptoms.  Vaginal estrogen comes in many forms – creams, suppositories, and even a ring filled with estrogen that is inserted every 3 months.  Vaginally-administered estrogen soaks into the cells and prevents age-related changes.  Although small amounts of these topically-applied, low-dose estrogen preparations make their way through the vaginal wall into the blood stream, it is just for a brief time after application.  So it is not believed they exert any significant effect on the uterus, the breasts, or other areas of the body.  Even women with a history of breast cancer can usually take this form of estrogen safely but, of course, they should always make sure their oncologists give them the go ahead.

The optimal time to start estrogen is right around the time of menopause.  If women delay initiating treatment, the aging effects that occur in the vagina and surrounding tissues will get gradually worse and some of the changes will become irreversible.  As long as treatment is continued, the beneficial effects will persist, but they will be lost if a woman decides to stop using estrogen.

For those women who cannot take any form of estrogen, there are other options.  A new product that just came out is Intrarosa (generic name is prasterone), which is basically DHEA.  DHEA is a precursor hormone that is converted into both estrogen and testosterone inside the vaginal cells.  It comes as a cream and is inserted into the vagina where it has the estrogen effects described above.  In addition, the testosterone produced is believed to increase blood flow, which further contributes to keeping the vaginal tissue healthy.  It also appears to have a stimulating effect on the nerves and may have the additional bonus of facilitating orgasms.  The downside of this new product is cost.  I, for one, will be interested in receiving feedback from patients as this product becomes more widely used.

Another recent option is an oral drug called Osphena.   This is a SERM, which stands for selective estrogen receptor modulator.  My book, The Estrogen Question, goes into greater depth on SERMs, but basically, they are designer drugs formulated to have either estrogen-like properties or estrogen-blocking effects.

One other new intervention you may hear about is laser treatment to improve vaginal symptoms.  This is in its very early forms of development, but is being performed in Europe and offered in some clinics in the United States.  Experts in the field of menopause advise women to be cautious when considering this treatment as much more research is needed to know how to best administer it.  And, additional studies are needed to tell us more about the long-term benefits and risks.