Vaginal Dryness

Vaginal Dryness

Vaginal dryness is a common symptom experienced by women in the perimenopause and menopause. However, as a result of embarrassment, it is rarely openly discussed and is often left untreated. Unlike the earlier symptoms of the menopause, the hot flushes and night sweats, the vaginal dryness caused by the lack of estrogen will persist and progress if left untreated.
 

What causes vaginal dryness?

Estrogen is vital to the health of the vagina, vulva, bladder and pelvic floor. At times of low estrogen (perimenopause, menopause, breast feeding, the progesterone only pill) the vagina starts to lose its natural lubrication, the walls of the vagina thin, become less elastic causing pain with penetration and an increased risk of tearing during sex. The bladder and the tube that empties it (urethra) also thin, the opening becomes more pronounced and urinary tract infection more common. The lips at the entrance to the vagina (the labia) lose fat, become thin and sensitive and can fuse together. This can cause itching and soreness leading to issues for some women with difficulty wearing pants or sitting for prolonged periods. Scars that resulted from childbirth lose collagen and elastin and can become more sensitive and often painful during sex.

Symptoms can occur in the perimenopause or may be delayed for several years and appear when a woman believes she is “through” the menopause. Once our ovaries have failed, we remain postmenopausal, estrogen is no longer produced. This can lead to women failing to understand that their symptoms are due to a lack of estrogen and missing the opportunity to access simple and effective treatment that can not only relieve symptoms but reduce their future risk of urinary tract infection, a common cause of sepsis in elderly women.

The older terms of vaginal atrophy and vulvovaginal atrophy are no longer used to describe this collection of symptoms that result from a lack of estrogen. Instead, the term Genitourinary Syndrome of Menopause is used to show that the bladder, urinary tract, vulva and vagina are all affected by this lack of estrogen.
 

What can be done?

Self help

Just as we apply moisturiser to our face and body, so we can apply moisturiser to our vagina and vulva. This can help to sooth the tissues. It is important to use a moisturiser specifically manufactured for use in the vagina and free of irritant additives. Yes VM and Sylk Natural Intimate Moisturiser are both recommended as they protect the acid vagina and provide the correct balance of moisture. Sylk can also be used as a lubricant to ease sex. Yes, lubricants are available as a water-based lubricant, Yes WB, and an oil-based lubricant, Yes OB. These can be used together with the oil-based lubricant applied first, followed by the water-based lubricant. Oil based lubricants should be avoided if condoms are being used for contraception.

Vaginal moisturisers can be applied every 2-3 days or more often if required.

If you are attending for a cervical smear or a vaginal examination, you can take your own lubricant for the healthcare professional to use thereby avoiding any potential contact with a lubricant that may adversely affect your vagina.
 

Treatment with local estrogen

The use of local estrogen in the vagina is a very effective solution that relieves symptoms of vaginal dryness usually after about 3 months. This can be prescribed by your doctor and can safely be used for most women on a long-term basis, if it is stopped, symptoms usually return. There are two types of estrogen – estradiol and estriol – and several methods of using it so you can choose the one that best fits your needs.

Local estrogen can be used as a tablet, pessary, cream, gel or ring:
 

Type

How is it used

Pros

Cons

Tablet

Vagifem, Vagirux

(estradiol)

 

Inserted high into the vagina using an applicator for 2 weeks and then continued twice weekly

Usually inserted at night

No mess

Easy to use

Vagirux has a reusable applicator so more environmentally friendly

Vagifem has a daily plastic applicator so lots of plastic waste

 

Vagirux requires the small tablet to be reloaded into the applicator so good eyesight and coordination are required

Pessary

Imvaggis

(estriol)

Inserted into the vagina using the fingers

Used once daily for 3 weeks and then continued twice weekly

No applicator so no waste

Can damage latex condoms

Can produce a slight waxy discharge

Cream

Ovestin

(estriol)

 

One applicator full inserted into the vagina once daily for 2 weeks and then continued twice weekly

Can be quite soothing if the vagina is very dry

Can be used on the vulva if this is dry and sore

Can be messy

Gel

Blissel

(estriol)

One applicator full inserted into the vagina once daily for 3 weeks and then continued twice weekly

Gel is rapidly absorbed

Itching or irritation may occur when first used

Ring

Estring

(estradiol)

Inserted into the vagina by the woman herself or by a healthcare professional

Stays in place for 90 days

No daily or weekly treatment

May interfere with sex – can be removed and replaced if required

 

In addition, Intrarosa is a pessary that does not contain estrogen but does contain prasterone which is converted to estrogen and testosterone in the body. It can be used once daily in the vagina to help women who are suffering from painful sex. It is easy to use but can damage latex condoms.
 

Use vaginal estrogen for 6 weeks prior to a cervical smear

If you have previously experienced pain while having a cervical smear, you can use local vaginal estrogen for 6 weeks prior to your next smear. This will help to ensure that you are more comfortable while having this very important screening procedure.

 

What to do if things are not getting better

Like all other aspects of HRT, women respond differently to the various forms of estrogen, so it is important to make an individualised choice with the help of your healthcare professional. Some women find benefit from the estradiol but not estriol and vice versa. It is worth a trial of a different preparation if you do not have success with your first choice.

If you have used your medication as prescribed for 3 months and you continue to have symptoms you should see your healthcare professional for examination. Other conditions can affect the vulva and vagina and may need alternative treatment, it is important to ensure that a correct diagnosis is made.  Any unexpected vaginal bleeding should always be discussed with your doctor.

Dr Alice Duffy

Last updated August 2021

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