Vaginal dryness, part of a condition known as Vulvovaginal atrophy (VVA), is a common and progressive problem that can affect the health and quality of life of many post-menopausal women.
Vaginal tissues require estrogen – as estrogen levels decline after menopause, women can experience dryness, itching, irritation, soreness, and pain during sex and afterward. They may also have associated urinary problems, needing to go frequently or urgently. Almost 50% of women will experience these symptoms, but often don’t discuss them their physician because they may feel the symptoms are not important enough or are too embarrassed to bring up the subject.
As the vaginal lining thins, fewer cells are shed from the surface, leading to lower production of lactic acid and higher pH (or less acidic environment). This decrease in acidity can make women more vulnerable to bacterial infection.
As well, decreased estrogen results in less vaginal blood flow and a decrease in vaginal lubrication. Muscles also respond to estrogen including those that support the bladder and uterus, so low estrogen can result in decreased support in the pelvic floor. Several effects of low estrogen can lead to a variety of vaginal problem for women.
What can women do if this happens? Well, depending on the severity of symptoms, there are several options…
If the main symptom is mild vaginal dryness, a basic sterile lubricant can be helpful – KY Jelly is one brand name, and many generics are available. This can be very effective if the main problem is discomfort during sex, and can simply be applied by either partner as needed.
The next “step” up, is an adhesive lubricant, such as Replens. This moisturizer is designed to adhere to the lining of the vagina, staying there for 2 to 3 days, providing ongoing moisture and lubrication. It’s designed to be inserted with the provided applicator 2 to 3 times a week.
If neither of these options are sufficient, or if there are associated urinary problems, then it makes sense to discuss the possibility of replacing estrogen with your doctor to help these tissues become healthier. But there are different choices when it comes to estrogen replacement too…
Some estrogens have stronger action in the body than others, and estrogen replacements come in different forms and milligram strengths. If the only problems are in the vaginal area, it makes sense to just replace estrogen in that area. Using a suppository or inserting a cream into the vagina would be preferred to taking an estrogen tablet by mouth or using an estrogen patch, where estrogen would be supplied to the entire body.
Of course, estrogen stimulates the growth of many cells in the body, not just the ones in the vagina. This group of hormones attaches to receptors and stimulates growth of cells in the breast, uterus, bone, skin, hair, muscles, brain and blood vessels – almost every part of the body.
There are 3 main estrogens in the body: estriol, estradiol and estrone, and the actions of these are not all the same throughout the body.
Estradiol is considered the main and most active form of estrogen, and it’s produced by the ovaries as the egg develops and after it is released at ovulation. It's the estrogen used in most supplements.
Estrone is thought to be a less favourable form of estrogen, as it is more readily stored and can be converted into more active estrogen later. Estrone and estradiol can be converted back and forth, and estradiol that is swallowed is mostly converted to estrone before it reaches the circulation. After menopause, estrone becomes the dominant estrogen and is created by conversion of male hormones produced in the ovaries and adrenal glands by enzymes in fat and muscle.
Estriol is a weaker estrogen that does not stimulate breast cells or lining of the uterus and only weakly improves hot flashes. It is the end product of the breakdown of other stronger estrogens and, when administered, is not changed. It is very effective in improving vaginal tissues, making it a useful estrogen for women with only vulvovaginal atrophy who wish to avoid any stimulation of breast tissue or uterus. It is not absorbed when swallowed and, perhaps for this reason, it has never been commercially manufactured. However, compounding pharmacists regularly prepare it in cream form for vaginal use. Estriol 0.5 mg inserted twice a week is often enough, although most women will use more initially to speed healing (up to 1mg daily, at bedtime for about 2 weeks, then reducing amount and frequency).
If you don’t have a compounding pharmacist in your area, vaginal estradiol would be my next choice. Be aware that it comes in various strengths, though, and only a small amount of estrogen is needed when it is being applied inside the vagina. Using larger amounts increases the likelihood of estrogen activity in other parts of the body.
To compare available products containing estradiol:
Premarin vaginal cream contains 0.625mg of estrogens per gram (about half is estradiol and the other half is equine estrogens that are also active), making it one of the stronger versions of vaginal estrogen on the market now.
In comparison, Vagifem is a suppository that contains only 10mcg (0.01mg) of estradiol per suppository – a huge difference! It is recommended to be used nightly until improvement (generally 2 weeks) then reduced to twice a week. It is interesting that Vagifem initially was sold as a 25mcg suppository, but the dose was reduced to 10mcg after further research. When using hormones in any form, it is recommended to use the lowest dose that will give satisfactory improvement.
Of course, estrogen is available in tablets and patches, but these are only recommended when additional intolerable symptoms occur in other areas of the body – hot flashes that interrupt sleep multiple times a night, for example. This type of hormone supplementation would help vaginal and bladder problems along with the other estrogen related symptoms, but the estrogen should always be balanced with progesterone to prevent over-stimulation of estrogen sensitive tissues and increased risk of cancer.
Lastly, due to a history of problems with hormones that are different than what our bodies produce, I always recommend using “bioidentical” hormones – those that are identical to what our bodies produce. And, although progesterone is thought to be unnecessary in those who do not have a uterus (since it was originally introduced to therapy to avoid an increased risk of uterine cancer), it makes sense to me after years of studying hormones to maintain the balance between estrogen and progesterone that nature provides whenever hormone replacement is being administered to the entire body, again using the same progesterone molecule that our bodies make.
Whatever therapy you and your doctor choose, however, remember that you always want to use the lowest level of treatment that will give sufficient improvement of your symptoms and to use it for the shortest time necessary.
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