Non-hormonal Remedies (Adapted from NAMS recommendation)
Vaginal lubricants are an excellent first choice in dealing with mild vaginal dryness during sexual activity. Their regular use may reduce discomfort with sexual activity. The choice of personal lubricant is often quite personal, but it is generally recommended that patients use a water-based lubricant to relieve the symptoms of vaginal dryness. The vaginal lubricant available through Rory is a safe, natural product that is long lasting and precisely mimics natural secretions. Oil-based lubricants may lead to increased infections and discomfort, and alcohol containing lubricants can burn.
Vaginal moisturizers help prevent itching and general discomfort by maintaining vaginal moisture. They are typically applied internally a few times/week at night to avoid leakage. The vaginal lubricant available through Rory can also be used as a daily vaginal moisturizer.
Regular sexual stimulation increases vaginal blood flow and results in increased secretions. The good news is that any sexual stimulation will be beneficial. It does not require a partner. However, as you will read below, combining stimulation with vaginal penetration helps to maintain the width of both the vagina and the introitus (the opening to the vagina). Again, a partner is not an absolute necessity to complete this exercise.
Vaginal dilators are helpful if there have already been some changes in the width, length, or flexibility of the vagina and the opening to the vagina. Used prudently and with guidance from a healthcare professional, dilators can be a safe and effective aid in regaining lost comfort and function.
Pelvic floor exercises (Kegel exercises) may be very helpful, especially if there is a tendency to “tighten up” due to pain when having sex.
Sexual pleasure and intimacy can include many activities other than penetrative vaginal intercourse. Orgasm can be achieved by both partners through genital stimulation by other methods. Occasionally, more explicit directions are required than those implied here, and the help of a sex therapist can be a very helpful step taken by a couple.
Systemic Hormone Replacement Therapy (Estrogen With or Without Progesterone)
Estrogen is the oldest, most effective prescription drug for the treatment of vaginal dryness (and other menopausal symptoms). It comes in oral, transdermal patch, vaginal ring, spray, and gel formulations. These formulations made from a group of related estrogens including conjugated equine estrogen (CEE), synthetic conjugated estrogens, micronized 17b-estradiol, and ethinyl estradiol.
In women who still have a uterus, these drugs should be used with a progestogen (progesterone) because estrogen alone increases the risk of endometrial hyperplasia and cancer. The exception is a drug called Duavee (conjugated estrogens/bazedoxifene). In this formulation, conjugated estrogen is paired with a selective estrogen receptor modulator (SERM) that protects the uterus. In general, it is recommended the lowest dose of hormones for the shortest duration possible be used.
Oral estrogen is highly effective in treating the local genital and urinary symptoms of menopause, as well. The Women’s Health Initiative (WHI) study scared many women and doctors away from the use of estrogen. This study enrolled around 27,000 women and had two treatment arms. In one arm conjugated equine estrogens (CEE) were used alone and in the other arm CEE was used together with a synthetic progestin called medroxyprogesterone acetate (MPA). Both of these groups were compared with a placebo group, which took neither drug.
The results of the study showed an increased risk of stroke and deep venous thrombosis (blood clots in the legs) in the CEE group with a decreased risk of hip, vertebral, and wrist fractures. There was no difference in overall mortality. The results also showed that the CEE+MPA group had an increased risk of stroke, pulmonary embolism (blood clots in the lungs), deep venous thrombosis (blood clots in the legs), and invasive breast cancer with a decreased risk of hip, vertebral, and wrist fractures. The CEE+MPA group also showed no difference in overall mortality.
However, the negative effects identified in this study differed based on the woman’s age. In women ages 50–59 who are fewer than 10 years postmenopausal and who don’t have contraindications, the risk of complications was not increased. Moreover, there seemed to be a benefit on total mortality (although it did not reach statistical significance).
Also, the WHI study was done with different chemicals than the ones naturally produced. The form of estrogen found in the body is call 17-beta estradiol and the form of progesterone is progesterone. These molecules are different than CEE and MPA used in the WHI study. Estradiol and micronized progesterone (both now commercially available) are identical to the natural hormones produced by the body. It is possible that the risks found in the WHI study would not be present with these hormones, but at present this is not known.
2) Ospemifene is daily tablet (taken by mouth) used to treat painful intercourse caused by vaginal atrophy. It is an estrogen agonist/antagonist, which means it works like estrogen (in places where you want more estrogen) and opposes estrogen’s effect (in places where estrogen could cause harm).
3) Dehydroepiandrosterone (DHEA) also treats vaginal atrophy but is placed in the vagina. Even though it can be converted into estrogen in the body, blood levels of estrogen do not seem to rise when it is used.