Vaginal Dryness

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 caused only by vaginal dryness, and actually can causing 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. Many times painful sexual activities are not caused by just vaginal dryness; they might be due to pelvic infection, endometriosis, ovarian cyst, etc. 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 uterus 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.

Vaginal Moisturizers

Most vaginal moisturizers are designed to increase vaginal fluid and maintain moisture and hydration of the vaginal lining. Some of the vaginal moisturizers are acidic, attempting to bring the vaginal acidity back to the pre-menopausal state, with a pH between 3.5 to 5. With normal vaginal acidity, there should be less risk of vaginal infection and a more optimal environment for the vaginal cells. Studies have reported that while estrogen vaginal products performed better in affecting the vaginal cell maturation to decrease the cell atrophy, the studied vaginal moisturizers improved vaginal dryness, irritation, acidity, and atrophy effectively. (Juraskova 2013, Sinha 2013, Le Donne 2011, Ekin 2011, Nachtigall 1994)

Vaginal moisturizers can be grouped into several categories according to the function of their main active ingredients. The categories and examples of products in each category are as follows:

• Bio-adhesive vaginal moisturizers – using polymers, such as polycarbophil, to bind to the vaginal lining to retain fluid to moisturize.

Replens, RepHresh, Yes

• Hyaluronic acid based vaginal moisturizers – Hyaluronic acid is naturally present in the tissues, functioning to maintaining the proper level of hydration, including in the vaginal wall. Hyaluronic acid related agents are used extensively in skincare products and as dermal fillers to correct wrinkles and lines.

Hyalo GYN, Hyalofemme, Repadina

• Prebiotic vagina moisturizers – using prebiotic enzymes, the formulation provides vaginal moisture and lubication for several days.

Luvena

Frequently Recommended Vaginal Moisturizers in the United States

Replens



Frequently recommended by physicians for women with vaginal dryness and painful sexual activities who do not want to use estrogen vaginal products. Replens is a vaginal gel with the main active ingredient polycardophil, a polymer that binds the gel to the vaginal wall to maintain hydration and moisturize locally. The gel is acidic, with a pH of 3, bringing the vaginal acidity back to the normal premenopausal range. The adhesive effect can last up to 3 days. Clinical studies by Nachtigall (1994) found that Replens had a similar effect as a vaginal estrogen product in improving vaginal moisture, vaginal fluid volume, and vaginal elasticity with restoration of a premenopausal vaginal acidity. Juraskova (2013) reported results of significant improvement in painful sexual intercourse, sexual function, and quality of life for breast cancer survivors by using a polycadophil-based vaginal moisturizer three times a week, combined with regular pelvic floor muscle relaxation exercises, and the use of olive oil as a vaginal lubricant. Replens is used with one vaginal application three times per week for long-term maintenance.

 

 

 

RepHresh



Besides polycarbophil, RepHresh has another polymer carbomer in its formulation. It’s effect lasts up to 3 days, and it is colorless, odorless, and acidic.

 

 

 

 

 

 

Yes

Yes uses a mixture of naturally occurring plant polymers to hold water to the vaginal lining, with effects lasting up to 48-72 hours. It restores the normal premenopausal vaginal acidity, and is claimed to have no skin irritants. Yes has a water-based preparation and an oil-based preparation, both using natural active ingredients.

Hyalo GYN

Its main active ingredient Hydeal-D is a derivative of hyaluronic acid which can resist enzymatic breakdown, making it more long lasting. Hyaluronic acid is the natural material in the body functioning to maintain fluid content and proper hydration of the tissues. Ekin (2011) compared hyaluronic acid vaginal tablets with estrogen vaginal tablets in the treatment of atrophic vaginitis. The results showed that both treatments provided relief of vaginal symptoms, improved vaginal thinning, and restored normal vaginal acidity. The improvements were greater with the estrogen treatment.

Luvena



This vaginal moisturizer contains several prebiotic enzymes, such as lactoferrin, lactoperoxidase, and also lactic acid to help moisturize and acidify the vaginal wall. It contains no parabens or glycerin.

 

 

 

 

 

 

Vaginal Lubricants

Vaginal lubricants are used during sexual activities to decrease friction and provide temporary relief to vaginal dryness and painful sexual intercourse. They generally do not have longer term moisturizing effects such as those offered by vaginal moisturizers. Vaginal lubricants are commonly used among women in the United States according to a study by Jozkowski (2013). In this study, women felt positive about the use of a vaginal lubricant during sexual activities, perceiving better satisfaction for the women and their partners. Women in their forties were reporting more positive perceptions of vaginal lubricants than women under the age of 30.

Vaginal lubricants are generally water-based or sometimes silicone-based. Some vaginal lubricants might cause irritation and also might increase the chance of vaginal yeast infections due to the glycerine content.

Vaginal lubricants are available without the need of a prescription. Some of the common over the counter vaginal lubricants are as follows:

K-Y Jelly



Water-based, containing cellulose compounds as active ingredients. It is colorless and odorless.

 

 

 

 

 

 

 

Astroglide



Water-based, containing glycol and paraben as ingredients.

 

 

 

 

 

 

 

Slippery Stuff



Water-based, containing carbomer and paraben as ingredients. It is odorless and non-staining.

 

 

 

 

 

 

 

 

 

Luvena Lubricant



Prebiotic formulation with bioactive enzymes and a moisture system to give effective vaginal lubrication.

 

 

 

 

 

 

 

References

Ekin M, et al. The comparison of hyaluronic acid vaginal tablets with estradiol vaginal tablets in the treatment of atrophic vaginitis: a randomized controlled trial. Arch gynecol Obstet. 2011 Mar;283(3):539-43.

Jozkowski KN, et al. Women’s perceptions about lubricant use and vaginal wetness during sexual activities. J Sex Med. 2013 Feb;10(2):484-92.

Juraskova I, et al. The accespability, feasibility, and efficacy (phase I/II study) of the OVERcome (Olive Oil, Vaginal Exercise, and MoisturixeR) intervention to improve dyspareunia and alleviate sexual problems in women with breast cancer. J Sex Med. 2013 May 1. doi:10.1111/jsm.12156.

Le Donne M, et al. The effect of vaginally administered genistein in comparison with hyaluronic acid on atrophic epithelium in postmenpause. Arch Gynecol Obstet. 2011 Jun;283(6):1319-23.

Nachtigall LE. Comparative study: Replens versus local estrogen in menopausal women. Fertil Steril. 1994 Jan;61(1):178-80.

Sinha A, et al. Non-hormonal topical treatment of vulvovaginal atrophy: an up-to-date overview. Climacteric 2013;16:305-312.