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 or bleeding during sexual intercourse. Vaginal secretions are also crucial in maintaining an optimum level of vaginal acidity, supporting the growth of "friendly" bacteria like lactobacillus, discouraging yeast infections. Our bodies host many different types of bacteria. These "good bacteria" 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 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 estrogen pills, low-dose vaginal estrogen reverses the atrophy of the vagina's lining by supplying estrogen directly to those cells. This approach restores vaginal elasticity and its ability to secrete lubricating fluids. Vaginal secretions encourage beneficial lactobacillus, reduce dryness, and make sexual activity more comfortable.
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. When used at appropriate doses, it doesn't create detectable estrogen levels 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. There are 3 different vaginal ring products available, each containing different estrogen concentrations.
Estring® has the least amount of estrogen and is worn for 90 days at a time for vaginal atrophy. Femring® has two strengths available 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 estrogen's action in vaginal tissue but blocks estrogen action in breast tissue. Osphena® is a pill taken daily by mouth.
Intrarosa® is a tablet containing DHEA (dehydroepiandrosterone) inserted into the vagina every night. This is more effective than supplements containing DHEA, which don't work well to ease vaginal dryness and increase breast cancer risk.
Testosterone vaginal cream is in clinical trials as an alternative to vaginal estrogen.
If you have significant vaginal discomfort, see your doctor. After ruling out infection or other issues, ask about whether low-dose vaginal estrogen or another medicine is a possible option for you.
Here Are 5 Tips to Help Relieve Vaginal Dryness:
1. 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.
2. 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®.
3. 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.
4. Premarin® vaginal cream is more effective than Estrace® or estradiol.
Although Estrace® and estradiol vaginal creams are slightly cheaper than Premarin®, they don't relieve symptoms as well.
5. Use more than one product.
Using a vaginal moisturizer plus locally applied estrogen, a lubricant, or all three, can improve your results.
Dr. Louise Achey, Doctor of Pharmacy, is a 40-year veteran of pharmacology and author of Why Dogs Can’t Eat Chocolate: How Medicines Work and How YOU Can Take Them Safely. Check out her NEW website TheMedicationInsider.com for daily tips on how to take your medicine safely.®2020 Louise Achey
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