July 2, 2001 -- Four years ago, at age 44, Seattle resident Caroline Scott Brown underwent a hysterectomy with removal of ovaries.
"Immediately after recovering from the surgery when I found out it was OK for me to start back having sex, I realized that it didn't feel comfortable," Brown says. "I was dry as a bone. It was awful. I was actually irritated just from touching my underwear, and I was avoiding sex.
Brown was suffering from atrophic vaginitis, a condition in which the vagina becomes dry and overly delicate in response to declining levels of the female hormone estrogen, says Andrew Kaunitz, MD. This decrease in estrogen happens naturally around menopause and temporarily while nursing a baby. But the hormone also drops off quite sharply in women who have surgeries like the one Brown had, especially when their ovaries, the glands that produce estrogen, are removed.
The changes women will notice are quite visible, says Gloria Bachmann, MD, associate dean for women's health at the Robert Wood Johnson Medical School in New Brunswick, N.J.
"One of the first signs one sees on pelvic examination is that the vaginal area is very dry, it's very pale, and it loses the wrinkling that most younger women have," she says. "As it progresses, the vaginal area gets thinner and smoother, and it easily bleeds. ... The degree of it is sometimes variable. A 50-year-old who comes in today to see me may have horrible symptoms, whereas another 50-year-old may not be at that point and may still have some lubrication."
All these changes can make atrophic vaginitis, "a very important but frequently not discussed caused of female sexual dysfunction," says Kaunitz, professor and assistant chairman of the department of obstetrics and gynecology at the University of Florida Health Science Center in Jacksonville and director of menopausal services for the University of Florida Medical Women's Center.
'Not an Automatic Thing'
Atrophic vaginitis occurs to a certain degree in all women as they age and their estrogen declines. Even women taking hormone replacement therapy are not immune because it is not always enough estrogen to keep things functioning normally.
And fortunately, not everyone will have the most troubling symptoms, which can have a major impact on quality of life, especially sex life.
"It's not an automatic thing," says Susan Love, MD, who specializes in women's health and is the author of many books on the topic, including Dr. Susan Love's Hormone Book. "In studies, only about 10%-20% of all women will get vaginal dryness [after menopause]. There are gradations."
Seeking Help and Staying Active
But for those women who are affected, many are embarrassed to discuss vaginal discomfort with their physician. Others feel that uncomfortable sex is a natural and unavoidable aspect of getting older. But nothing could be further from the truth, says Kaunitz.
"Women can continue to enjoy good sex as they age, and this common condition is very preventable and treatable," he says.
Bachmann says women can be confused when loss of vaginal lubrication starts before their periods have stopped. "Many women will erroneously believe there's something wrong with their relationship or something that is stressing them in their life," she says.
Early diagnosis and treatment of atrophic vaginitis is important because the condition often gets worse with time if left untreated.
"Sexual activity, particularly intercourse, helps maintain your ability to lubricate," says Love. "What tends to happen is, if you're not lubricating and it's a little bit painful, then you stop having sex. Then sex is more painful, so you start having it less, and it becomes a self-fulfilling prophecy. Even masturbating is good for increasing the ability to lubricate."
Some Treatment Options
The simplest treatments for any form of vaginal dryness are lubricants and hydrators, available in any pharmacy. These include water-based products such as KY Jelly, Astroglide, and Replens, which are more comfortable to use than oil-based petroleum jelly. And unlike petroleum jelly, they can be safely used with condoms.
Unfortunately, these lubricants, while helpful, are often not a complete solution for women with atrophic vaginitis. There weren't enough for Caroline Scott Brown.
"They were kind of messy," she says. "They did help, but they didn't totally solve the problem and then an hour later I was dry again. That's when I started researching [prescription] products and called my doctor."
For decades, relief has been available in the form of prescription creams that contain estrogen. They are placed directly in the vagina and although effective, they can be messy, and the estrogen is absorbed into the bloodstream. This can be a problem for women taking hormone replacement therapy because they don't want to increase the amount of female hormones in the blood even more. It is an even bigger problem for women who have or have had diseases, such as breast cancer, that thrive in an estrogen-rich environment.
Still, for women who don't mind a little extra estrogen in their systems, these creams are often effective. If you do choose this option, Love recommends you "use a little dab on your finger ... . Do that every day for about three weeks and then about three times a week after that."
And don't use estrogen cream as a lubricant with a male partner because they can absorb it, too -- and chances are they won't like that.
Recently, a company called Pharmacia has started manufacturing two new products for atrophic vaginitis that overcome some of the disadvantages of estrogen creams. One, called Vagifem, is a tiny pill, about the size of a baby aspirin, that is inserted high into the vagina with an applicator about the size of a pencil.
"Even women who have developed quite a lot of atrophy, or even narrowing or shortening of the vaginal canal ... can comfortably use this tablet because the applicator is so slender," says Kaunitz.
Inside the body, the pill dissolves slowly over a few days to release small amounts of estrogen. A new pill must be put into place about twice a week.
More recently, Pharmacia has begun marketing a product called Estring, which is a ring that is also inserted high into the vagina. It slowly releases estrogen over about three months, at which time the ring is removed and discarded and a new one is inserted.
Both Vagifem and Estring are easy to use and, once inserted, cannot be felt at all. They also do not fall out no matter how active you are. Although they increase the amount of estrogen in the vagina, blood levels of estrogen do not appear to go up. As a result, many physicians feel they are safe even for women with breast cancer.
Brown tried both and decided Vagifem is the best option for her.
"What I noticed immediately was that I had just normal lubrication," she says. "It felt natural. Even when I wasn't having sex, the whole vagina area just felt better, normal."
The Alternative Approach
There are some alternative remedies that appear to be helpful.
Luc Maes, ND, DC, is a chiropractor and specialist in naturopathic medicine in private practice in Santa Barbara, Calif.
The first thing he does with patients who have what looks like atrophic vaginitis is rule out infections or other conditions, such as diabetes. If the vagina is very irritated, he uses vaginal suppositories made with soothing calendula and vitamin A. Vitamin E oil, which can be obtained by cracking open a vitamin E capsule, can also be used directly in the vagina to increase lubrication and soothe the vaginal lining.
To increase the amount of estrogen in the vagina, Maes uses products based on plants that are high in substances called phytoestrogens, which act similarly to estrogen. These include creams used as well as supplements taken by mouth. He also recommends all women approaching menopause to maintain overall good health with proper diet and exercise.
Love also uses some alternative therapies. Like Maes, she recommends using vitamin E to soothe and lubricate the vagina. For some women, she also recommends taking supplements of black cohosh, which is high in phytoestrogens, in the form of a standardized product called Remifemin. She also suggests that women eat one to two items of food a day that contain soy protein, which also has some estrogen-like action in the body.
She does not recommend, however, taking isoflavone supplements. Isoflavones are believed to be the active ingredient in soy, but this is not yet clear, and it is also not certain whether taking high doses of this extract is either safe or effective.
Knowing What's Right for You
Of the myriad therapies available, choosing the one product or combination of products that's right for you has to do with how severe your symptoms are as well as what you are comfortable using.
"If you are having more and more difficulty or pain with intercourse and are postmenopausal or have had a hysterectomy," says Love, "you're better off going [directly to a] hormonal [treatment] because it's going to work faster."
Kaunitz says many women don't have complete relief unless they combine a prescription product with an over-the-counter lubricant.
Remember, some of these products may not be right for you, especially if you have had breast cancer. Your doctor can tell you which are safe to try and which to steer clear of.
Discussing It With Your Doctor
But how do you talk to your doctor about such a sensitive matter? Don't be daunted if your doc asks you about every symptom of menopause but this one.
"Not all physicians are going to broach the topic, and women can play a very proactive role by bringing it up themselves," says Kaunitz. "I think in general, women will find that ob/gyns are going to be more comfortable with this topic than family physicians or internists, although that is not universally true. If women bring up sexuality or genital-related concerns and don't find the physician is knowledgeable or comfortable, they may want to look elsewhere."
"Women need to realize this is not their fault, and they are entitled to have pain-free sexual activity if they want," says Love. "Sometimes, the doctor is embarrassed. You need to feel you're braver than they are and bring it up in a very matter-of-fact way."
It helps to remember that many, many women suffer from this condition, says Brown. She also recommends that "women keep a journal and write down exactly what it is they're feeling and figure out a way to produce an opening [with their doctor]. I said, 'I have another major problem we need to solve.'"
"No matter what we are dealing with, we should not feel shame because we have a particular issue," says Brown, who now hosts motivational and self-esteem seminars with her husband. "All women need to feel good enough about themselves to believe that they in mid-life are worthy of continuing to have a good sex life."