What is Vaginal Dryness?
Vaginal dryness is a delicate topic for many women during perimenopause, menopause and beyond. From the bathroom to the bedroom, it can cause physical and emotional distress that’s difficult to explain to your doctor, partner or even your best friend. Since vaginal dryness is directly linked to declining estrogen levels, women will experience it for the rest of their postmenopausal life. The good news is that, with Rory, you have the support and resources to help you through this midlife change.
Getting the proper amount of high-quality sleep is necessary to function at your best. High quality sleep is uninterrupted and it slips smoothly through each sleep cycle (discussed below). Your body and mind both suffer if either your quality or duration of sleep is insufficient. Prolonged periods without proper sleep can compromise nearly every aspect of your health.
The American Academy of Sleep Medicine and the Sleep Research Society recommend that adults sleep 7 or more hours per night on a regular basis for optimal health. Despite this advice, the CDC estimates that about 35% of adults sleep fewer than 7 hours per night. Sleeping fewer than 7 hours is associated with (either causing or caused by) many diseases, including:
Hypertension (High Blood Pressure)
Increased risk of death
Poor immune function
Higher risk of accidents
Why is it so common with menopause and perimenopause?
Menopause is defined as the cessation of menstrual cycles that occurs when a woman stops ovulating permanently due to a loss of eggs (ovarian follicles). As part of this process, the ovaries stop producing large amounts of estrogen (and progesterone). It is only diagnosed after a woman has not had a period for 12 months. The average age of menopause in the United States is 51 years old but it is possible to experience it at a much earlier age. About 1% of women will experience menopause before age 40 (premature menopause) and 5% will experience it before age 45.
Perimenopause is defined as the transition from having regular menstrual cycles to the complete cessation of menstrual cycles. It usually begins when a woman who previously had cycles that were regular with a predictable length begins having irregular periods before eventually having no periods at all. Women enter perimenopause on average about 4 years before they stop having periods altogether.
It is in this early period just before menopause when symptoms like vaginal dryness can start to appear. The most common symptom during perimenopause and menopause is hot flashes/flushes, which is estimated to occur in over 75% of women during midlife, but vaginal dryness is also remarkably common.
Subtle changes occur throughout the reproductive system, including the vagina—and unlike hot flashes and other general menopausal symptoms, vaginal changes do not improve with time, and often worsen with each passing year. The decreasing levels of estrogen cause the vaginal tissue and the vulvar skin (outer lips of the vagina) of the genitals to become atrophic—meaning the skin begins to lose its normal, thick structure.
The vagina also becomes more susceptible to yeast and other infections. The once healthy balance of organisms that was supported by a slightly acid, vaginal environment is altered in the less acidic, estrogen-deprived vagina of menopausal women.The term used to describe all the changes that occur in the vagina and vulva is vulvovaginal atrophy (VVA).
Other symptoms related to the loss of estrogen in the genital region include urinary tract symptoms (e.g., frequent urination, a sense of urgency, loss of urine with stress, need to urinate at night) since the skin in the area of the urethra (the tube that carries urine) is affected by the loss of estrogen.
Taken together, symptoms of menopause involving the vaginal tissue and the urinary tract are called the Genitourinary Syndrome of Menopause (GSM). You will often see vulvovaginal atrophy (VVA) and Genitourinary Syndrome of Menopause (GSM) clumped together as VVA/GSM. GSM includes all the symptoms that may occur and respond to therapy as described below.
What changes are causing the dryness I feel?
Before perimenopause or menopause, the vagina is usually moist with skin that is pink from abundant blood vessels. There are multiple folds of extra skin and mucous secreting sebaceous glands that can produce moisture quickly during sexual excitement.
When estrogen is lost the skin becomes thin, pale, and dry. The vagina narrows and shortens. The opening to the vagina, called the introitus, can narrow, as well—especially when penetrative sex is not practiced.
The vaginal skin can become so thin that small breaks in the blood vessels (now far fewer in number) can occur, the once abundant folds of extra skin disappear, and the vagina loses much of its capacity to expand when needed.
The sebaceous glands may remain but they do not function well. The natural lubrication women experience with stimulation is both lessened and delayed.
What might I experience with these changes?
NAMS’s (The North American Menopause Society) position paper on VVA (vulvovaginal atrophy) states, “Symptoms…such as lack of lubrication and pain with intercourse, affect 20% to 45% of midlife and older women but only a minority seek help or are offered help by their providers.”
Vaginal dryness is more than a minor inconvenience for many of the women with the condition.
The VIVA (Vaginal Health: Insights, Views & Attitudes) online survey asked women how the vaginal discomfort associated with vaginal dryness affected them. The results were striking:
80% considered it to affect their lives negatively
75% reported negative consequences on their sex life
68% reported that it makes them feel less sexual
36% reported that it makes them feel old
33% reported negative consequences on marriage/relationship
26% reported a negative effect on self-esteem
25% reported that it lowers Quality Of Life (QOL)
Despite the toll it takes, vaginal health is commonly not addressed by healthcare providers during perimenopause and menopause. In the largest survey of US women, REVIVE (Real Women’s Views of Treatment Options for Menopausal Vaginal Changes), only 7% of the 3047 women in the study reported that their healthcare provider asked them questions about VVA.
The authors of the Viva Survey concluded, “Vaginal atrophy negatively impacts women’s lives, but women lack knowledge of the subject and are hesitant to consult healthcare professionals, who should proactively initiate discussions regarding appropriate treatment options.”
Vaginal dryness is associated with a number of significant symptoms that may be missed unless the question is asked. The REVIVE study reports, “The most common VVA symptoms were dryness (55% of participants), dyspareunia—pain with sex (44%), and irritation (37%). VVA symptoms affected the enjoyment of sex in 59% of participants.” Also, sleep was disturbed in 24% and enjoyment of life diminished in 23%.
Few women knew that their symptoms were associated with menopause and hormone changes. Yet, the personal consequences of unaddressed vaginal dryness are significant. In the REVIVE study,
85% of partnered women had some loss of intimacy
59% indicated symptoms affected their enjoyment of sex
47% of women with partners said their symptoms interfered with their relationship
Vaginal dryness and the other vaginal changes associated with menopause are not minor inconveniences for many women. They can be life-altering.
Vaginal dryness treatment options
Vaginal Estradiol 0.01% is a prescription cream containing plant-derived estrogen used to treat the symptoms of moderate to severe vaginal dryness (e.g., itching and burning) that is the result of the decreased estrogen levels of menopause. Learn more about vaginal estradiol here. To learn more about risks and benefits, including the boxed warning, click for important safety information.
The Rory personal lubricant is a water-based personal lubricant that is glycerin free, paraben free and 100% vegan. The ingredients are purified water, plant cellulose (from cotton), carrageenan, organic aloe, natural vitamin E, organic cyamopsis (guar gum), potassium sorbate and citric acid. The Rory personal lubricant is safe to use with all types of toys, condoms and sexual activity. Learn more about personal lubricant here.
What are other treatment options?
There are a number of steps women can take to prevent and treat vaginal dryness related to menopause. This includes everything from exercises to topical estrogen therapy, and many treatments can be used in combination. You and your healthcare provider should balance the benefits and the risks in the use of any treatment.
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.