The Menopausal Vagina Monologues

About half of menopausal women suffer from vaginal dryness and painful intercourse. Yet less than half of those women seek help.

At a cocktail party at my home a few months ago, I started chatting with a few middle-aged women, including a few I barely knew. After brief introductions, the conversation quickly turned to a topic that’s become typical banter among women of my age: menopause. But this time, it bypassed hot flashes and went right to sex.

It wasn’t until one of the male guests sauntered over and asked what we were discussing that the conversation came into sharper focus.

“Uh, dry vaginas,” said a friend. He didn’t leave.

About half of menopausal women suffer from vaginal dryness and painful intercourse. Yet less than half of those women seek help. For many women, the discomfort arrives so insidiously that they don’t link it to the hormone changes of menopause, doctors said.

When estrogen plummets during menopause, the vaginal lining thins. In addition to vaginal cells, estrogen influences cells that line the urethra, bladder and vulva, said Dr. Stacy Lindau, a professor of obstetrics and gynecology at the University of Chicago and director of WomanLab, a website that addresses issues of women’s sexual health. “When estrogen is doing its job, it improves blood flow and maintains the elasticity of the vagina,” she said.

The hormone shifts also alter the kinds of “good” bacteria that reside within the vaginal lining, changing the acidity level as well. The upshot is an internal environment that is drier and stiffer. And unlike hot flashes, which subside within a few years for some 80 percent of menopausal women, vaginal dryness tends to get worse.

While doctors can assess the appearance of the vaginal lining and measure blood flow and acidity, test results may not correlate with symptoms. Some patients who seem to have a vagina that would cause pain are not in discomfort, whereas others with a healthy exam report distress.

“Symptoms should be the be-all and end-all of what we care about,” said Dr. Caroline Mitchell, the director of the vulvovaginal disorders program at Massachusetts General Hospital. “The good news is that there are a lot of things that can help, and for most people, things will get better.” She added that, unfortunately, most women will not get 100 percent relief.

Treatment choices include lubricants, applied just before intercourse to reduce the sand-papery feeling in the vagina; moisturizers, used about three times a week to keep the vagina moist; and estrogen that plumps the vaginal wall lining. The estrogen is either in systemic doses — taken as an oral pill, a patch or a gel. Or it is formulated to give a dose that mainly stays in the vagina — as a vaginal tablet, a cream or a ring.

The Food and Drug Administration recently approved Intrarosa, a vaginal suppository containing DHEA, short for dehydroepiandrosterone, a hormone that is converted into estrogen inside cells and that may reduce pain, said Dr. Mary Jane Minkin, an obstetrician-gynecologist at Yale University.

A recent 12-week study in JAMA Internal Medicine of 302 postmenopausal women found that estrogen (in the form of Vagifem, a vaginal tablet) was about as effective as a vaginal moisturizer (Replens) or a placebo tablet or gel in providing relief.

“Estrogen is not some sort of miracle for everyone,” though for some, “I think it’s great,” said Dr. Mitchell, who led the study. Dr. Lindau said of the treatments that were tested, “the point isn’t that they all did nothing, but they all did something.”

Alternative therapies are popular, but there is no proof they work. Eating yogurt rich in probiotics, for instance, is a common remedy, but it does not change vaginal flora. “It sounds like a good idea,” said Dr. Mitchell, “but the bacteria are not the same ones in the vagina, so that isn’t going to help.”

Websites sell marijuana douches or topical cannabinoids, the active ingredient in marijuana, that claim to lubricate the vagina. But no studies show they alter the vaginal microbiome or are effective, though high doses may get into the bloodstream and provide some relaxation, Dr. Mitchell said.

The MonaLisa Touch, a laser therapy, has been offered as a hormone-free way to reverse vaginal dryness, but there are no long-term randomized studies proving its efficacy for this purpose. “We haven’t reviewed or approved these devices for use in such procedures,” said Dr. Scott Gottlieb, the F.D.A. commissioner, in a recent statement.

Dr. Lindau added that painful intercourse may not always be a result of hormonal changes. Some women are dry from using too much soap. “This hyper hygiene activity — too much washing and wiping — there is no good reason to use soaps, certainly not in the vagina or in the vulva,” Dr. Lindau said.

Other women may have pain limited to the opening of the vagina that can be eased with a lidocaine ointment, a numbing cream. Painful intercourse may also be caused by spasms on the opening of the vagina or abnormal growths.

One 78-year-old woman was surprised to find the ease of intercourse improved after her recent hip replacement surgery. What she thought were vaginal issues was discomfort from her hip pain.

Sexual problems can also arise, of course, from relationship issues.

“I don’t want the knee-jerk reaction to be that every vaginal complaint needs to be treated with estrogen, though low estrogen is a common cause of itchiness and dryness.” Dr. Lindau said.

She suggests trying existing therapies — and giving each one a good shot.

To be sure, it wasn’t that long ago that women broke the taboo of menopause talk and began sharing experiences about hot flashes along with the pros and cons of hormone therapy. Now that menopausal woman are more open to talking about vaginal dryness, they are seeking help — but often not soon enough. Then what began as a hormonal problem can turn into a relationship issue, too.

“Women have been led to believe that if they were just nicer to their partners or a little less anxious, their vaginal dryness would go away,” Dr. Lindau said. “But more often it’s the physical changes of menopause that are driving these issues — and they are treatable.”

Randi Hutter Epstein is the Writer in Residence at Yale Medical School, an adjunct professor at Columbia University Graduate School of Journalism and the author of “Aroused: The History of Hormones and How They Control Just About Everything.”


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