Vaginal Dryness, Especially During Intimacy
While vaginal dryness, especially during sexual activities can occur at any age, it is a more frequent issue for women entering midlife. As women are getting closer to, or have gone into the menopausal state, vaginal dryness, especially with sex, often becomes an issue. Menopause is defined as a state when the ovaries stop producing the female hormones – estrogen and progesterone. Vaginal moisture and vaginal mucosal (the vaginal lining tissue) functions are dependent on the level of estrogen – absence of such causes decreasing vaginal moisture and thinning of the vaginal mucosa. Menopause is a state that a woman will be in once the cessation of the ovarian functions occurs and will remain so the rest of her life. While some of the menopausal symptoms, such as hot flashes, may eventually subside after a few years, the vaginal dryness will only get worse. While taking estrogen replacement orally or applying to the skin might help with systemic symptoms, such as hot flashes and night sweats, there might not be sufficient replacement estrogen to supply the needed hormone to the vagina to reverse the dryness and thinning. Increasing systemic estrogen would also increase the estrogen risk of breast cancer and blood clots. The vagina needs to be treated locally to retain and regain vaginal moisture and thickness.
Interestingly, sexual activities will increase vaginal moisture and improve vaginal thickness and function. Paradoxically, stopping sexual intercourse due to painful sex will only make vaginal dryness and thinning worse. Of course, it would be totally unacceptable to even suggest having sex while it is painful, but the vicious cycle of vaginal dryness, painful sex, more vaginal dryness, more painful sex…. needs to be broken. The treatment of the vaginal dryness has to be local, and it need not be estrogen only, especially prescription estrogen. There are natural solutions to vaginal dryness. Once the vaginal moisture is restored, with proper vaginal lubrication, naturally or with supplements, sex is pleasurable again. More sex, more vaginal moisture and thickness – a positive cycle to overcome vaginal dryness and to restore vaginal health and improve intimacy.
While estrogen is known to stimulate the cells in the vaginal mucosa (vaginal lining) to make them grow and produce more moisture, there are natural and synthetic agents that may do the same or directly moisturize the vagina without directly affecting the cell functions of the vaginal wall. These agents basically increase the moisture content of the vaginal tissue – fluid between the cells, without directly stimulating the cells.
There is a difference between a vaginal moisturizer that treats vaginal dryness specifically by increasing the fluid content within the vaginal tissue, and a vaginal lubricant which just lubricates the vagina to decrease the friction during sex without necessarily moisturizing the vaginal tissue. Basically, one can use a vaginal moisturizer regularly to increase the vaginal fluid content to overcome vaginal dryness and then use the vaginal lubricant episodically with sex. There are products that are both a vaginal moisturizer and a vaginal lubricant. There are merits to that concept, but it certainly should not be viewed as superior to the individual vaginal moisturizer used regularly and the use of a vaginal lubricant as needed approach.
Vaginal Dryness and Related Symptoms
- Vaginal dryness and the feeling of being more “sensitive” in the vaginal area.
- Vaginal irritation, burning, soreness including the vaginal opening and the labia.
- Vaginal discharge and increased infection, occasionally unpleasant odor.
- Painful sexual activities.
- Slight bleeding with sexual activities.
- Decreased sexual activities and desire.
- Loss of confidence in sexual relationship.
Common Causes of Vaginal Dryness
Vaginal dryness and the related symptoms such as sexual difficulties can occur at any age. Also, sexual difficulties might not be caused only by vaginal dryness, and actually can lead to vaginal dryness. The common causes for vaginal dryness, some apply to any age, are as follows:
- Menopause – the natural cessation of the ovarian functions, usually around age 50, causes decreased production of estrogen – the female hormone. The lack of estrogen causes thinning and dryness of the vaginal lining.
- Surgical menopause due to the removal of the ovaries, or menopause caused by chemotherapy or radiation.
- Child birth and breast feeding – affecting the estrogen level.
- Vaginal infection, vaginal bacterial imbalance, and occasionally and paradoxically the treatment of such.
- Medications such as decongestants, anti-estrogen medications such as Lupron.
- Certain birth control pills.
- Vaginal douching, feminine hygiene spray or bath soaps.
- Inadequate sexual stimulation prior to intercourse.
- Sjogren’s syndrome, an auto-immune disease with dry eyes and mouth also; other vulval diseases such as lichen sclerosis.
How to Find Out the Causes of Vaginal Dryness
It is most important to see your physician to openly discuss your vaginal dryness and associated problems, including sexual dysfunction, embarrassing as that might be. You want to be sure that if there are any problems causing the vaginal dryness, they should be treated or addressed so you can get your life and confidence back. Often painful sexual activities are not caused by just vaginal dryness; they might be due to pelvic infection, endometriosis, ovarian cyst, and so forth. Painful sexual activities due to these pelvic pathologies might actually be causing the vaginal dryness in response to the pain. This is why it is important for you to see your doctor about vaginal dryness or painful sexual activities and not just assume that they are due to menopause or an “age” thing. Women are entitled to have normal vaginal health and sexual fulfillment in middle life and way beyond.
Your doctor should ask you the relevant questions relating to the vaginal dryness and the associated problems, such as painful sexual activities, and perform a pelvic examination that could include a pap smear and a culture for bacteria or yeast. If indicated, your doctor may order a urine test or a blood test to check for menopause hormone level, for example.
Treatments for Vaginal Dryness
Your doctor will recommend specific treatments for the causes of vaginal dryness, for example, antibiotics for a bacterial vaginal infection. For menopausal patients, after excluding other causes for the vaginal dryness, the doctor might recommend the use of estrogen replacement therapy. Estrogen products to the vaginal area usually are more specific and effective to treat vaginal dryness than a systemic estrogen, such as those taken orally or through a skin patch or gel. Your doctor will discuss with you the risks and benefits of hormone replacement therapy so you can make the decision as to whether or not to use prescription estrogen medication to treat the vaginal dryness and the associated problems, including painful sexual activities.
The prescription vaginal estrogen products can be in a cream form to be inserted into the vagina by an applicator or applied topically. The other forms include tablets or a ring to be inserted into the vagina.
The FDA has approved an oral medication, Ospemifene, which is a selective estrogen receptor modulator that can improve the symptoms of vaginal dryness and thinning with the associated painful sexual activities for menopausal women. However, it carries the boxed warning of increased risk of uterine cancer and blood clots in the deep veins.
Home, Natural, Non-Prescription Treatments for Vaginal Dryness
After making sure that you have checked with your doctor and excluded causes for the vaginal dryness or painful sexual activities that should be treated medically, there are home, natural, and non-prescription remedies that one can use to help with vaginal dryness and painful sexual activities. Other than the vaginal estrogen prescription products discussed above, there are several vaginal products in the over the counter market that can help to relieve the symptoms of vaginal dryness and the related painful sexual activities. Basically, there are two classes – vaginal moisturizers and vaginal lubricants.
Vaginal moisturizers help to restore the moisture or fluid content in the vaginal mucosa, which is the vaginal lining. They can be used frequently, just like using skin moisturizers for dry facial skin. The vaginal moisturizers can help in decreasing vaginal dryness symptoms, such as irritation, sensitivity, soreness and painful sexual activities. However, they do not cure the underlying causes of vaginal dryness, and most of them are not that effective as a lubricant for sexual activities.
Vaginal lubricants are designed to lubricate during sexual activities. They help women who have difficulty with producing natural lubricant, which can occur before or after menopause, with or without vaginal dryness issues. They help with only the lubrication and are not vaginal moisturizers. Therefore, they should be used only for the purpose of enhancing lubrication during sexual activities to decrease discomfort. Some vaginal products claim to be both a vaginal moisturizer and a vaginal lubricant.
Since there is so much publicity and marketing information out there concerning vaginal rejuvenation or laser vaginal rejuvenation, some claiming to restore vaginal youth or lubrication, it might be helpful to discuss such treatments, referring to the following Blog posting by Dr. Lau. Actually, since the posting of the blog, the FDA came out with a warning to the public about the risks of using those energy devices and the lack of proven efficacy by such.
LASER OR THERMAL REJUVENATION OF THE VAGINA – DO THEY WORK? – A recent Blog by Dr. Lau
There are two main types of energy devices that are being marketed for non-invasive vaginal rejuvenation. The trend is in response to the surge in popularity of vaginal rejuvenation.
Both types of energy devices being marketed are actually extensions from their existing counterparts that have been used extensively for years in face and body applications. The two classes of energy devices are as follows:
This group of laser products, such as MonaLisa Touch and Alma Lasers FemLift, are fractional carbon dioxide (CO2) laser devices, similar in technology to that of Fraxel lasers for facial and body skin applications but adapted to the vagina. The idea is, just like that of the skin treatment, to ablate dots of epithelial lining tissues to stimulate new tissue growth over the ablated areas, in this case the vaginal mucosa lining. The original indication for such ablation is to thicken the vaginal lining for patients that are menopausal with thinning of the vaginal epithelium, but who cannot use estrogen replacement due to history of breast cancer. The claim is that the ablation could thicken the vaginal lining, and therefore restore the pre-menopausal state of lubrication and comfort.
In practice, the thickening of the vaginal mucosa could indeed provide lubrication and decrease irritation, especially with sexual activities. However, the same effect can be achieved by using a very small amount of estrogen vaginal cream, such as Premarin or Estrace vaginal cream, massaging into the vaginal and vulval areas a few times a week. Of course, the vaginal cream is much less costly and can be used long term to maintain the corrective effect.
Since the action of the laser is very shallow, limited only to the superficial lining of the vagina, there should be little, if any, effect in tightening the vaginal canal or opening. While the laser treatment might “rejuvenate” the mucosal lining of the vaginal wall, it is rather different in effect from a formal vaginal rejuvenation procedure, where the muscles and fascia of the vaginal wall are tightened physically. This will optimize the internal size of the vagina to enhance sexual function and rebuild the vaginal opening and part of the labia to achieve a youthful aesthetic effect externally. Furthermore, the superficial effect of the current lasers is temporary at best.
RADIOFREQUENCY THERMAL DEVICES
The radiofrequency (RF) thermal devices, such as Thermi VA, use radiofrequency – electric current – to heat up the tissue to cause the tissue to contract due to the thermal effect on the collagen and other tissue matrix molecules. The technology is an extension of the RF technology used for tightening of the skin of the face and body, with devices such as Thermage. The amount of heating is controlled with a thermostat system to maintain an optimal temperature of the tissue to be heated. The heating effect, while deeper than that of CO2 laser, is still superficial in nature. It can heat up the tissue of the vaginal lining and the immediate underlying tissue, but most likely not the deeper muscle layer where most of the tissue defects occur with vaginal and vaginal opening relaxation secondary to vaginal childbirth. The vaginal muscle and deep fascia defect would usually require tightening using sutures, often in a minimally invasive procedure setting.
There are three major differences between vaginal rejuvenation and the rejuvenation vaginal treatment by the RF heating method. First, the standard vaginal rejuvenation procedure tightens the muscle groups and deep fascia around the vaginal canal to reduce and optimize the size of the vaginal canal to improve the sexual function. The muscle and deep fascia defects are caused usually by vaginal childbirth, and the defects usually require plication using sutures. It would be improbable to achieve such correction by simply heating up the vaginal mucosal lining and some of the superficial underlying tissue.
Second, while there could be some subjective improvement noticed by both the woman and her partner in sexual activities after the RF treatment, the durability of such improvement could be a concern. Without the tightening of the underlying deep fascia and muscle layers, the superficial tissue could stretch out with time and activities.
Third, to give the desirable youthful aesthetic effect by tightening the often-seen gap of the vaginal opening secondary to childbirth and aging, the excessive tissues in the perineum and the bottom part of the labia majora have to be reduced and the torn tissue and muscles reconstructed. That can only be done using resection and suturing, even if it is through minimally invasive means.
In summary, the treatment of the vagina with energy devices as discussed could achieve some subjective improvement in the short term. If there is a need for proper correction of the function and aesthetic concerns of the vagina, it would be prudent to seek advice from a qualified vaginal plastic and cosmetic surgeon to explore the best options. Most of the time, the corrective procedures can be done using only local anesthetics and through a minimally invasive approach.