The Ouch of Vaginal Dryness

Q: I’ve had vaginal dryness and burning ever since menopause. K-Y® Jelly doesn’t help much. What else could I try?

You have a lot of company. According to one survey, 60% of all women past menopause experience vaginal discomfort, yet most don’t ever mention it to their doctor because they consider it just another sign of aging.

Menopause causes a cascade of changes in a woman’s body. As the supply of estrogen dwindles, many women experience hot flashes, sleep disturbances, fatigue, and vaginal changes. Breast cancer survivors and those taking medicines like Aromasin® (exemestane) or tamoxifen experience these changes even earlier.

Without the influence of estrogen, the cells that line the vagina and birth canal begin to shrink, or atrophy. They become thinner, less elastic, and less able to secrete lubricating fluids. This leads to vaginal dryness, burning, and itching along with pain and bleeding during sexual intercourse. Ouch!

Vaginal secretions are important, not just for enjoyment of sexual activity but also for their role in maintaining a healthy vagina. They provide an optimal level of vaginal acidity, also called pH. A pH of less than 5 in the vagina discourages yeast infections and encourages “good bacteria” called lactobacillus, crowding out “bad bacteria” and helping prevent bacterial infections.

The simplest, most effective way to reverse vaginal atrophy is to apply a small amount of estrogen directly to vaginal cells. This locally applied estrogen physically changes the cells that line the vagina into younger cells, restoring elasticity and lubricating secretions, changing the pH toward optimal levels and reestablishing beneficial lactobacillus.

Non-estrogen options include using a long-acting vaginal moisturizer regularly to maintain vaginal pH or a more traditional type of personal lubricant right before sexual activity. Many women with vaginal atrophy find they need a product that’s more lubricating than traditional K-Y® jelly.

Can a breast cancer survivor safely use locally applied estrogen to reverse vaginal atrophy? The evidence says YES. It turns out that you don’t need much estrogen if you can apply it directly to the cells. Researchers have documented how locally applied estrogen reverses the signs and symptoms of vaginal atrophy without affecting other areas of the body. When used at approved doses, locally applied estrogen doesn’t trigger any changes in the cells lining the uterus or create any detectable levels of estrogen in the blood.

Locally applied estrogen is available as several products: estrogen cream with a separate applicator (Premarin®, Estrace®, and generic estradiol), vaginal tablets with individual applicators (Vagifem®), and a gelatin ring that releases estrogen (Estring®). The starting dose for the cream and vaginal tablets is once daily at bedtime for 2 weeks, then twice a week as maintenance. Estring® is a prescription-only vaginal ring that’s inserted and left in for up to 3 months. Estring® only works locally, on the tissue it touches. This is different from another vaginal ring called Femring®. Femring® has more estrogen in it than Estring® and is designed to relieve hot flashes and other menopausal symptoms.

Then there are two non-estrogen vaginal moisturizers: Replens® and Restore®. Replens® is a fragrance-free, long-acting moisturizing vaginal gel that supplies up to 3 days of moisture in between applications. Non-prescription Replens® is available as premeasured doses inside individual plastic applicators or as a tube with one reusable applicator. Unlike estrogen, Replens® doesn’t change your vaginal cells, the pH of your vagina or restore its lactobacillus. It does, however, “clean up” debris from old, dried up cells as it begins to work. The package insert warns about vaginal discharge during the first week of use as old cells slough off and come out, like cottage cheese. After that, any discharge is clear and minimal.

Restore® is a fragrance-free “moisturizing personal lubricant” that is all natural and organic from Good Clean Love. It has no polypropylene and the main ingredient is aloe, with help from Oregon grape and calendula. Restore® is designed to match healthy vaginal acid levels and salt balance. I like the applicator, which attaches to the top of the tube so it’s always available. Like Replens®, Restore® doesn’t require a prescription.

Osphena® is a prescription pill taken daily which works on estrogen receptors in the vagina to reduce the pain of sexual intercourse, called dyspareunia. If your insurance doesn’t pay for it, it may cost up to $160 for a month’s supply. However, Osphena® doesn’t do a very good job at relieving vaginal dryness and is definitely NOT intended for anyone with a history of breast cancer.

Which option is best for you? If you have had or are at high risk of breast cancer, I suggest you talk to your doctor about prescription-only vaginal tablets. Some women combine vaginal tablets with estrogen cream applied to the outside tissue. If this isn’t enough to relieve your symptoms, adding a non-prescription lubricating gel like Replens® or Restore® may help. If you don’t have a high risk of breast cancer, using an estrogen cream vaginally is also an option. Please tell your doctor about your discomfort and explore the options of locally applied estrogen for vaginal dryness.