Q: Since menopause, I’ve noticed more and more vaginal dryness. Is there anything besides hormone pills that can help?
You are not alone. Over 75% of post-menopausal women, plus many women taking anti-estrogen medicines like aromatase inhibitors for breast cancer treatment or prevention suffer from vaginal dryness and discomfort.
Without estrogen, the cells lining the vagina and birth canal begin to shrink or atrophy, losing elasticity and secreting less lubricating fluid. Vaginal atrophy creates dryness, itching, burning, even pain and bleeding during sexual intercourse.
Vaginal secretions are also important in maintaining an optimum level of vaginal acidity, which supports the growth of “friendly” bacteria like lactobacillus discourages yeast infections.
Our bodies host many different types of bacteria that live on our skin, inside our mouth, and along our intestines and vagina. Some are helpful, but others aren’t. Lactobacillus is a “good” bacteria, helping to keep out “bad” bacteria and prevent vaginal infections.
Today there are low-dose estrogen and non-estrogen options that can successfully treat the vaginal atrophy and discomfort.
Replens® is a long-acting moisturizing vaginal gel that gives up to 3 days of moisture between applications. It’s available without a prescription in premeasured doses inside individual plastic applicators and as a tube with a reusable applicator. Although it relieves dryness and burning and makes sexual intercourse more comfortable, Replens® won’t change your vaginal cells, the pH of your vagina or restore lactobacillus.
Instead of taking estrogen pills, low-dose vaginal estrogen reverses the atrophy of the lining of the vagina by supplying estrogen directly to those cells. This approach restores both elasticity and the ability to secrete lubricating fluids that increase the acidity of the vagina and encourage beneficial lactobacillus.
Can a breast cancer survivor safely use low-dose vaginal estrogen to reverse the symptoms of vaginal atrophy? The evidence suggests YES. You don’t need much estrogen when applying it directly to vaginal cells, and when used at appropriate doses, it doesn’t create detectable levels of estrogen in the blood that could reach endometrial or breast tissue.
There are several forms of low-dose vaginal estrogen: vaginal creams used with an applicator (Premarin®, Estrace®), vaginal tablets with individual applicators (Vagifem®), and a gelatin ring that releases estrogen (Estring®). The starting dose for the cream and vaginal tablet is once daily at bedtime for 2 weeks, then twice a week as maintenance.
Estring® is a vaginal ring that’s inserted and left in for up to 3 months. As a pharmacist, I have to be careful when filling prescriptions for vaginal rings because there are 3 different ones available, each containing a different amount of estrogen. Estring® has the least amount of estrogen, and is worn for 90 days at a time, for vaginal atrophy. Femring® has two strengths available designed to relieve hot flashes and other menopausal symptoms, worn for up to 90 days. NuvaRing® is used for birth control and worn for 3 weeks at a time with one week off.
Other prescription options for vaginal atrophy include Osphena® and Intrarosa®. Osphena® mimics the action of estrogen in vaginal tissue but blocks estrogen action in breast tissue, and is a pill taken daily.
Intrarosa® is a tablet containing DHEA (dehydroepiandrosterone) inserted into the vagina every night. You should avoid DHEA supplements, as they don’t work well and may increase risk of breast cancer.
Testosterone vaginal cream is in clinical trials as an alternative to vaginal estrogen.
If you have significant vaginal discomfort, see your doctor to rule out infection or other serious issue, then ask about whether low-dose vaginal estrogen or another medicine is a possible option for you.
5 Tips to Help Relieve Vaginal Dryness:
- Use a long-acting vaginal moisturizer.
Estrogen-free Replens® is available without a prescription. If you try it, watch out for some weird vaginal discharge during the first week of use, when dried out vaginal cells slough off and come out, looking like cottage cheese.
- Apply a lubricant.
You’ll find a lot of choices available today for a “personal lubricant” for sexual contact besides the old standby, K-Y Jelly®.
- Assess the relative risks between the various options available.
Discuss your options for vaginal estrogen and other prescription medicines for relief of vaginal dryness with your physician.
- Premarin® vaginal cream is more effective than Estrace® or estradiol.
Although Estrace® and estradiol vaginal cream are slightly cheaper than Premarin®, they don’t relieve relieving symptoms.
- Use more than one product.
Using a vaginal moisturizer plus locally applied estrogen or a lubricant (or all 3) can improve your results.
