Vaginal dryness is the most bothersome symptom of the menopause – in addition to hot flashes. It is also the one that is most ignored by women and least effectively treated by doctors, even though it affects quality of life so severely and even though excellent treatment exists.
Vaginal dryness is the most bothersome symptom of the menopause – in addition to hot flashes. It is also the one that is most ignored by women and least effectively treated by doctors, even though it affects quality of life so severely and even though excellent treatment exists.
Vaginal dryness is one of the most bothersome symptoms of menopause
There is a progressive drop in the level of estrogen in the body as you go through menopause. Several changes like hot flashes, mood swings, body ache tend to settle as the years pass. However, vaginal dryness due to low estrogen levels tends to continue to be bothersome and even get worse as age advances.
Decreasing estrogen levels cause the vagina to become dry, inelastic and thinned out. This is called atrophy. Studies show that vaginal atrophy is present in over 34% of women as they go through menopause and over 80% of post-menopausal women have some symptoms relating to vaginal dryness.
If you find talking about intimate issues embarrassing, you are not alone. Over 77% of women find talking about vaginal dryness uncomfortable and even in countries like the US, Canada and UK 42% of women did not know that vaginal dryness treatment exists.
Many women who do pick up the courage to talk about vaginal dryness symptoms don’t always get the treatment they need. Studies found that over 63% of women who had symptoms of vaginal dryness and atrophy had never been prescribed treatment. Yet, the same studies showed that 67% of those treated reported positive effects.
In this article we will talk about the different causes of vaginal dryness (focusing on menopause), the effects it can have on quality of life, the treatments currently available and some newer treatments that should become available soon. We will also talk about home remedies, non-hormonal treatments and some strategies to make these treatments work for you.
Vaginal dryness – causes
Vaginal dryness negatively affects quality of life
There are several reasons for vaginal dryness. Some reasons can happen along side menopause and complicate both the presentation and treatment.
- Decreasing estrogen and androgens as you go through menopause.
- Surgical menopause caused by a hysterectomy where the ovaries are removed.
- Medication you may be taking – anti allergy tablets, tablets for urinary incontinence, some antidepressants.
- Radiation or chemotherapy for cancer treatment.
- Anti-estrogen medication used to treat endometriosis or uterine fibroids.
- Certain illnesses that have dryness as a part of their presentation – e.g Sjogren’s syndrome.
- Emotional or psychological issues – stress, anxiety, depression, loss of desire, pain during sex.
- Diabetes mellitus can worsen symptoms of menopause and vaginal dryness in particular.
Symptoms of vaginal dryness
When the vagina loses the support of estrogen as you go through menopause, it becomes thinner and less elastic. If sex is infrequent, the vagina can become shorter and tighter and tear easily when you do have sex.
The drop in estrogen also affects the vulva, perineum and anus. These changes affecting the genitals in women who go through menopause are clubbed under the terminology – genitourinary syndrome of menopause.
Vaginal dryness is the symptom that women report as being most bothersome, second only to hot flashes.
The vaginal dryness can cause itching, burning and stinging sensations
The vagina and vulva can feel itchy and a burning sensation can cause distress. Even wearing underwear can sometimes become uncomfortable.
Some women report burning when passing urine or stools or a sensation of urgency or having to go often. Other bothersome symptoms are urinary incontinence, burning and stinging when passing urine, and pain with intercourse.
Vaginal dryness during sex can cause it to become painful and distressing and there starts a vicious cycle of pain – loss of arousal – no orgasm – loss of desire – relationship stress- anger- fear- loss of intimacy – loss of desire – and the cycle continues only to deteriorate with age.
Women don’t talk about painful intercourse or vaginal dryness during intercourse, because they feel embarrassed. When questioned, over 40% admit to having pain with sex – this is called dyspareunia. These are the women who are still having sex! We know that over 50% of women simply stop having sex altogether or have sex very infrequently when they go through menopause. You can read more in my article about sex and menopause.
Sex can become painful and uncomfortable and destroy intimacy
All these symptoms are worse in women who undergo treatment for cancer. The challenge lies in being able to achieve some relief from these bothersome symptoms without using hormone therapy that can aggravate hormone dependent cancers or cause them to recur. Eventually, treatment is more a matter of quality of life than just how it affects recurrence or survival.
Menopause and vaginal itching
As estrogen levels drop and the vagina becomes dryer and thinner, the cells also lose the usual glycogen content that special bacteria called lactobacilli love. This means that these bacteria no longer have the food they need to thrive and keep the pH of the vagina acidic.
As the pH of the vagina changes, so does the bacterial population – often called vaginal microbiome. This change can mean that fungus like candida grow more easily.
Vaginal itching at menopause can be simply because of the dryness and sensation of irritation or it can be because of an overgrowth of candida. This is particularly important if you suffer with diabetes or are taking antibiotics or steroids for other illnesses.
Menopause and vaginal discharge
As vaginal dryness sets in, the quality and quantity of vaginal discharge you experience changes.
Most women have a cyclicity to vaginal secretions that they get used to through their reproductive years. The clear discharge of the first half of the cycle compared to the thicker whiter discharge once you ovulate and the discharge associated with an expected period.
Once menopause sets in and estrogen levels decline, this cyclicity is lost. Although the vagina feels dry most of the time, there may still be a discharge of some kind. If an infection sets in, the discharge can become yellow and sticky and stain underwear. If it becomes smelly it is best to see a gynaecologist to get a diagnosis and appropriate treatment.
Menopause and vaginal odor
Most women are familiar with how their genitals smell. The smell that is normal for them comes from pheromones secreted from sweat glands on the vulva. Vaginal secretions also have typical smell although this is affected by what we eat and drink and whether there is an infection.
Menopause and the associated decreasing estrogen levels, changes the quality and quantity of sweat produced by the sweat glands on the vulva and also the vaginal secretions.
Vaginal dryness in menopause is the most bothersome symptom
The normal bacteria that reside in the vagina and feed on glycogen, which is dependent on circulating estrogen now have a challenge. The drop in estrogen with menopause changes this bacterial population. This changes the quantity and quality of vaginal secretion.
If there is an infection, typically with bacteria from the anus – vaginal discharge can become smelly and discolored.
Generally speaking, postmenopausal vaginal dryness and discharge is likely to be an ongoing problem. It is best to seek treatment early and get reviewed regularly so that quality of life is not affected severely.
Vaginal dryness – diagnosis
A study found that vaginal dryness was the commonest complaint and worsens with age (upto 64% of women over the age of 55 years). This is followed by painful sex (54%), itching (38.5%), burning (38.3%) and pain when passing urine (29%)
When you see your doctor about menopause and symptoms that bother you do talk about vaginal dryness and how it affects you. The doctor will most likely also take a detailed medical and drug history to determine the cause. As we have already seen several other problems can be associated with vaginal dryness at menopause.
What the doctor uses to confirm the diagnosis is a visual inspection of the vulva and vagina so be prepared to have an internal examination. The vagina often looks dry and pale. Sometimes the examination itself can cause stretching and small tears that bleed easily – this is called mucosal fragility. These signs all become worse with age and if the change is associated with radiation or chemotherapy for cancer.
Some additional objective tests are the vaginal maturation index which looks at the changes in the cells of the vagina for the effects of estrogen. Vaginal pH measurement is also a marker of the level of estrogen in the cells. This is because in the presence of estrogen the vaginal cells hold glycogen. When the normal bacteria in the vagina break down glycogen for their purpose, it keeps the pH of the vagina acidic (between 3.5 and 4.5). When the pH remains acidic only certain types of bacteria can survive and they are the ones that constitute the normal vaginal microbiome.
When the pH of the vagina is disturbed because of lack of estrogen, douching, sexually transmitted infections, antibiotic use etc. other organisms like candida (a fungus) can take over and cause an infection.
If there are obvious signs of infection by the presence of a smelly discharge, redness and pain on examination, the doctor may also take a swab to check for infection. A pelvic floor assessment will also help at this point to decide if you need help with a physiotherapist.
Vaginal dryness treatment options
There are several treatment modalities available for managing the problems associated with vaginal dryness. Vaginal dryness is one of the earlier symptoms of decreasing estrogen levels that then lead to atrophic changes in the vagina.
We talked about atrophic changes as those that cause the vagina to shrink or tighten or become friable. These atrophic changes associated with decreasing estrogen levels tend to persist or worsen as you age. Suffice to say that vaginal atrophy is easier to prevent than treat
So, it appears that early diagnosis and treatment can make a big difference to the effect that vaginal dryness has on overall quality of life. Treatment can prevent the progressive damaging effects of low estrogen with ageing.
The mainstay of this condition has always been estrogen and associated hormones like progesterone, DHEA and testosterone. Estrogen helps to thicken the vagina, improve its flexibility and stop it from shrinking.
However, many women are concerned about the side effects of hormone therapy including risks of breast cancer, hyperplasia of the lining of the womb, strokes and heart disease.
Concerns about these side effects were raised over a decade ago and women have preferred to use complementary and alternative therapies to manage their symptoms.
Hormonal methods include oral, transdermal (with patches or gels on the skin), or vaginal preparations containing estrogen alone or in combination with progesterone, testosterone and DHEA (a hormone that acts as a precursor for estrogen and androgens in the body). Drugs like Bazedoxifine and Ospemifine are newer medicines that are being studied for the treatment of menopause symptoms. Vaginal oxytocin has also been studied as a treatment method.
Non-hormonal methods include herbal remedies, vitamins, vaginal moisturizers, oils and blended preparations, laser treatment, physiotherapy for the pelvic floor.
Vaginal dryness treatment options
Psychosexual therapy and cognitive behavioral therapy have been used to improve sexual functioning and arousal by teaching the woman and her partner how to manage menopausal symptoms better and not allow them to affect intimacy and closeness.
Conclusion:
In menopause, women may encounter discomfort due to vaginal dryness. Hormonal remedies like estrogen tablets, gels (e.g., Vagifem, Premarin) offer relief. Alternatives like oxytocin, DHEA gel, and even testosterone address diverse needs. Innovative medications Ospemifene and Bazedoxifene broaden treatment options. Laser and radiofrequency devices provide hormone-free solutions to enhance vaginal health during menopause. If home remedies fall short, consult your doctor confidently.
Share your thoughts with me at masterthemenopause@gmail.com. Your insights are valued as we navigate through menopause, ensuring a comfortable journey.
References:
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