The tissues of the vagina and vulva are estrogen sensitive, which means that there are hormone receptors in these tissues. As hormone levels wane at menopause, the epithelium (layers of skin) that line the vulva and vagina become thin. The blood vessels in the surrounding supportive tissues decrease. The mechanism of vaginal moisture and lubrication come from these vessels. When a woman is sexually excited, fluid flows from the blood vessels into the walls of the vagina. With less blood flow, there is less fluid. Along with this is a decrease in collagen and elastic fibers that make the walls of the vagina more pliable and stretchy. It is no wonder that intercourse can be painful.
Not everyone experiences these changes, but many women do. If you have remained sexually active in perimenopause, and have intercourse once or twice a week, you may be less likely to experience discomfort. The first course of action is the use of lubricants. Personal lubricants can be purchased over-the-counter or on the internet. They can be applied to the vaginal opening, and there are several brands that can be inserted into the vagina. They can also be applied to the male penis. If intercourse is comfortable with a lubricant, that is all you may need.
Many women find that even with lubrication, intercourse is painful. The next step is to use vaginal estrogen. Vaginal estrogen can go a long way to restoring the integrity of the tissue of the vaginal wall. Vaginal estrogen comes in three different modes of therapy, There are estrogen creams that are inserted into the vaginal canal. These creams are not intended to be lubricants to be used with intercourse. Instead, they are usually inserted into the vagina at bedtime, twice weekly, which allows absorption into the vaginal tissues. Some women find the creams messy, as they may leak out during the day. Some women forget to use the cream as often as directed, and do not achieve the expected benefit.
Another mode of delivery of estrogen into the vaginal wall is to use a pill that contains vaginal estrogen. This pill is also inserted twice weekly, although it may be used every day for the first two weeks of treatment, to provide a more immediate benefit. The third product is an estrogen containing ring, that secretes a small amount of estrogen per day. Studies have shown that this method of delivery of estrogen to the vaginal wall does not increase serum (blood) levels of estrogen. The ring in inserted by the doctor or patient, and is changed every three months. Women who have used a diaphragm in the past find it very easy to insert and remove. Unlike a diaphragm, it does not need to be placed to cover the cervix. It is merely inserted into the vagina, and will often settle around the cervix. Women and their sexual partners most often do not feel the ring when it is in place.
The product that is right for you is the one which you find easiest to use and most effective. All of them work well for many women, but not all. Many women also notice that vaginal estrogen has a beneficial effect on urination. Frequency, urgency, and bladder infections can occur more commonly after menopause, and the estrogen effect of strengthening the vaginal tissue provides more support to the bladder, which is attached to the upper vagina.
Physicians are often asked if vaginal estrogen is safe. Women who have had breast cancer, uterine cancer, or blood clots, and who should not be on hormones wonder how much systemic absorption will occur from vaginal products. Some women just do not want to use estrogen at all. There is no doubt that inserting an estrogen product into the vaginal wall allows estrogen to be absorbed into the blood stream. Absorption is usually greater when the tissue is very thin, but as tissue integrity improves, less is absorbed. Most physicians feel that the amount is small, and there is no evidence that the small amount of estrogen will increase the risk of breast or endometrial cancer, or a recurrence of breast cancer in women who have already been treated for beast cancer.. A small percentage of women who use vaginal estrogen will note mild systemic symptoms such as breast tenderness.
There are women who may consider using systemic hormone replacement therapy because vaginal estrogen does not work well enough. Systemic therapy may be very helpful, and may also eliminate other menopausal symptoms while providing some prevention of osteoporosis. The risks and benefits must be determined by your physician.
Some women, despite lubricants and vaginal estrogen, still find intercourse very uncomfortable. There is a medication, ospemifene, which is a selective estrogen receptor modulator, that acts like estrogen on the vaginal wall. Scientists have produced a set of drugs, called SERM’s, that act like estrogen on certain tissues in the body, but on other tissues, actually function as an estrogen antagonist. This SERM acts like estrogen in the vaginal wall, and its effect on breast tissue has not fully been studied, so it is contraindicated in women with a history of blood clots or breast cancer, and should be used cautiously in women who are at risk of cardiovascular disease. Preliminary date demonstrates that ospemifene is safe for the breasts.
A gynecologist is Italy developed a novel treatment for vaginal dryness, utilizing a laser similar to what dermatologists use to eliminate wrinkles of the face. He adapted the technology that has been used for more than twenty years by plastic surgeons and dermatologists to rejuvenate the facial skin, and applied this to the vaginal wall. The laser pulse is fractionated, which means that it penetrates the tissue at intervals. The laser energy stimulates the growth of normal vaginal tissue, increasing the layers of epithelium, causing increased regeneration of blood vessels, and along with it the growth of more collagen and elastic fibers. This treatment, although expensive, is a valuable alternative for women who do not get the desired effect from lubricants and vaginal estrogen, or who prefer or should not use estrogens at all.