13

HORMONE HELL

How to turn back the clock on your vagina
when your estrogen tank is on empty

Six years ago, I started dating a really nice man. I mentioned to him that I was scheduled to attend a three-day medical conference on menopause and vaginal dryness. Later I heard him on the phone talking to one of his friends. “Three days of lectures on vaginal dryness? I can’t believe there is that much to talk about!”

I pointed out to him that if every man in America woke up on his 50th birthday to discover that his testicles had atrophied, his penis had shrunk to the size of a breakfast sausage, and ever having sex again was completely out of the question, there wouldn’t be a mere three-day medical conference on the subject. A national emergency would be declared, and the surgeon general would be on network television to address the crisis. Men would be flocking to the pharmacy to stock up on testosterone. Internists would certainly not be suggesting to their male patients that they stop using their testosterone after a year to “see how it goes.” Thankfully, he got it. I married him.

Menopause officially occurs when your ovaries permanently stop producing estrogen or are surgically removed. For many women, the onset of menopause represents freedom from monthly cramps, bleeding, and PMS. Sadly, for many it also represents the end of what was once a healthy, satisfying sex life. No matter what other issues you have that affect your sexual health, this is the one that is universal to every woman—if not now, then in the future. Hot flashes, vaginal dryness, insomnia, mood swings, brain fog. It’s a very special time of life. But given increasing life expectancy, women today can expect to live almost 40 percent of their lives after the menopause transition. As far as I’m concerned, nothing less than symptom-free is acceptable.

All female mammals, with the exception of humans and whales, die shortly after the onset of menopause.

In our culture, most women know that “the change of life” is associated with hot flashes, which while not exactly welcome are at least expected. And yet, a surprising number of otherwise savvy women are not aware of the association between lack of estrogen and the onset of symptoms such as painful intercourse and vaginal irritation. Surveys show that only about 50 percent of women are even aware that vaginal dryness is a direct result of menopause. They only know that, seemingly overnight, slippery sex has turned into sandpaper sex.

Flashes Are Fleeting, Dryness Is Forever

It’s also surprising to me how many women assume that all symptoms of menopause are temporary and that once the hot flashes go away, menopause is officially over. A few years ago I was giving a lecture on postmenopause problems at a large women’s convention. Before the talk, I was wandering around and heard many of the women say, “I’m done with menopause, so I don’t need to hear that talk!”

Well, since postmenopause is defined as the time in a woman’s life when she is no longer producing estrogen, no one is ever finished with menopause, until of course she is dead. She may not have hot flashes, insomnia, or brain fog anymore, but she will never produce estrogen again. In other words, while some symptoms of menopause are temporary, the inability to produce estrogen is permanent. The symptoms of menopause that will not go away without intervention are those associated with vaginal atrophy. In fact, vaginal atrophy only gets worse. Much worse.

When does the dryness hit?

For 4 percent of women, in perimenopause

For 21 percent of women, in the first year after menses stops

For 47 percent of women, within three years postmenopause

In addition, while hot flashes occur early on in menopause, the symptoms of vaginal atrophy sometimes don’t appear until years later. Many women don’t even associate a new onset of painful intercourse with menopause, which explains why women were skipping my lecture on menopause. However, the ones who did attend the lecture were floored to learn that their vaginal dryness was a treatable, reversible problem shared by many other women.

What Happens to the Vagina When Estrogen Production Stops

Years before estrogen production completely shuts down, hormone levels start to fluctuate wildly during that special time of life known as perimenopause. While the average age to stop menstruating is 51, there are vaginal changes that begin long before you officially donate your tampons to your daughter.

Without estrogen to stimulate the estrogen receptors on the vulva, vestibule, and vagina, the lubrication normally provided by moisture from the cells that line the vaginal wall, the secretions of Bartholin’s glands and of Skene’s glands, and cervical mucus pretty much disappears. In addition to becoming dry, the collagen layer in the vagina diminishes, making the walls tissue-paper-thin. Changes also occur inside the individual cells. Vaginal cells produce glycogen, which is necessary for lactobacilli to survive. (Remember them, the good guys in your vaginal ecosystem?) The lactobacilli also convert glucose to lactic acid, which keeps the pH of the vagina at a healthy 3.5 to 4.5. It is only at this normal pH that there is protection from vaginal and urinary tract infections.

Diminished blood flow, especially if you smoke or have vascular problems, diabetes, or any of the other medical illnesses discussed in chapter 15, only make things worse.

In short, soon after you blow out the candles on your 50th birthday cake, your vaginal walls dry up and become thin and inelastic, the folds (rugae) in the walls disappear, and the vagina shortens and narrows. You become a frequent flyer at your gynecologist’s office to figure out why you always seem to have a yeast infection, bacterial vaginosis, irritation, and odor. And this is all just about what is happening inside the vagina.

If Mother Nature were really a woman, we would keep our vaginal wrinkles and lose our face wrinkles.

External Physical Changes

Sometimes the external physical consequences of low estrogen are subtle, but sometimes the changes are so striking that you can’t help but wonder if you had a vulvar/vaginal transplant in the middle of the night. (Whose vagina is this and how did it get in my body?)

When estrogen levels decline, pubic hair is often diminished, but with the current hairstyle of minimal pubic hair, that’s not something every woman notices or worries about. The vulvar skin often becomes pale, dry, and not as stretchy. Labia minora can become smaller (why oh why couldn’t it be the hips!), and in severe atrophy actually start to fuse together. The labia majora often appear to be bigger, but in actuality that is an optical illusion. It’s the labial fat that has diminished (why oh why couldn’t it be the hips!), making the labia majora seem more pendulous, the labia minora less distinct, and sometimes the clitoris more prominent. The urethral opening also appears more prominent and sometimes looks red. The vaginal opening, yes, actually gets smaller. (Why oh why . . . oh forget it!)

The medical term for these physical changes is vulvovaginal atrophy, but I prefer the term genital dryness. (Remember chapter 1!) Symptoms of vulvovaginal atrophy, aka genital dryness, include:

Dryness

Burning

Painful intercourse

Vaginal discharge

Genital itching

Painful urination

Urinary urgency

Recurrent urinary tract infections

Bleeding after intercourse

Fissures after intercourse

Decreased lubrication

It’s hardly shocking that for women with this condition intercourse can become excruciatingly painful, or simply impossible. Even a Pap test can cause bleeding and inflammation.

Before Botox, one look at a woman’s face told her age. Now you have to rely on the appearance of the inside of her vagina to know if she is in the over-50 club. The vagina doesn’t lie.

Other Consequences of Atrophy (It’s Not Just About Sex)

Atrophy from lack of estrogen is not just about sex: it’s about having a healthy vagina. No one wants her vagina to emit an odor or constantly be irritated and uncomfortable, but that’s what can happen as a consequence of the higher pH and an altered ecosystem.

Estrogen is also intimately tied to bladder health. That’s right—since there are estrogen receptors in the bladder and urethra, a lack of estrogen is also responsible for an overactive bladder, urethral discomfort, urinary frequency, and recurrent urinary tract infections.

Sylvie came to see me because she kept getting yeast infections. She mentioned that she needed to take a lot of antibiotics because of frequent bladder infections. Her frustration was obvious, and she mentioned that she had an appointment with a third urologist to figure out what was going on. She had already had a cystoscopy, a CT scan, and too many cultures to count, but so far no answers as to why she kept getting bladder infections. She was shocked when I told her all she needed was a local vaginal estrogen to eliminate the UTIs. Sure enough, when I saw her six months later she reported that she’d had no further problems.

The Scope of the Problem

The current life expectancy for women in the United States is 81. The average age of menopause is 51. Right now in the United States, roughly 50 million women are no longer producing estrogen.

Not every woman has vaginal atrophy as a result of menopause, but over 50 percent report that they have symptoms of atrophy such as painful intercourse and “vaginal discomfort.” The number of women who have issues is doubtless higher, since the number of women who discuss those symptoms with their doctors and seek care is astonishingly low—at best, around 20 to 30 percent.

By 2030, 1.2 billion women will be postmenopausal.

Making the Diagnosis

It’s not rocket science to figure out what’s going on when a 52-year-old patient tells me that six months after her period disappeared her vagina became like the Sahara Desert and sex was suddenly a nightmare. I’m pretty sure what the problem is about 90 percent of the time after just talking to my patient. I still need to do an exam to confirm the diagnosis, since other things could be causing similar symptoms, but vaginal atrophy is generally the culprit. More important, I need to determine the degree of the problem to know what the solution will be.

During the exam, I pay specific attention to the external tissues of the vagina, noting whether they are thin and dry. Sometimes I see splits in the skin. The speculum exam clinches it when I see vaginal walls that are pale with no rugae, no lubrication, and sometimes even bleeding just from inserting the speculum. I also routinely measure vaginal pH, so that I have an objective indicator of the degree of the atrophy and can monitor improvement over time.

With rare exception, I don’t need to measure blood estrogen levels to diagnose a lack of estrogen. A nonexistent estrogen level in a 53-year-old woman who has not had a period in two years and has a vagina that looks like the surface of the moon is expected, just like getting a sky-high pregnancy test in someone who is nine months pregnant. It doesn’t tell you anything you don’t already know.

The Fix

It makes me totally crazy when I read magazine articles that tell women who have stopped having sex after menopause that all they need to do to solve the problem is to “plan a special date night,” “try sex in the kitchen,” or even worse, “watch a sexy movie together” to rekindle the magic and perk things up. These articles are generally written by someone in her twenties who has absolutely no idea what is actually going on in a 50-year-old vagina. I know because I am frequently interviewed for these articles.

Some women, especially if their atrophy is mild, only need to use a good vaginal lubricant to get back in the saddle. Having read chapter 5, you are now an expert on the different types of lubes. But choosing the right lubricant is only the first step. You need to know how to use it correctly. (Please refer back to chapter 5 for that lesson!)

Estrogen

It would be nice if lubricants always solved the problem, but sometimes the ravages of menopause make the vaginal walls so thin and dry that the only way to reverse the vaginal clock and make intercourse comfortable is to use estrogen. I know . . . estrogen. Everyone thinks breast cancer, blood clots, bad stuff. And if you weren’t thinking that, you will when you read the FDA-required package insert that comes with the prescription.

There are two general categories of estrogen therapy:

Systemic estrogens are intended to work throughout the body to alleviate symptoms such as hot flashes. The blood level you achieve with estrogen therapy is not intended to be as high as when you were 20 (which is why it is called estrogen therapy as opposed to estrogen replacement), but high enough to alleviate symptoms. Sometimes systemic estrogen relieves vaginal dryness, but not always. A systemic estrogen may be oral (a pill), or it may be transdermal in the form of a spray, patch, gel, or cream. One vaginal product, Femring, delivers systemic-level doses in the same range as transdermal and oral products. (For the details about systemic estrogen therapy, see chapter 14.)

Local vaginal estrogens are products that are placed in the vagina to specifically alleviate the symptoms of vaginal atrophy. While some vaginal estrogen is absorbed into the bloodstream, the amount is minimal and its effects are local rather than systemic. For that reason, vaginal estrogen has no impact on your hot flashes, bones, or brain.

Vaginal Estrogen—Creams, Rings, and Other Things

There are three types of local vaginal estrogen products to treat postmenopause vulvovaginal atrophy, all of which meet the following strict criteria imposed by the FDA.

For starters, women enrolled in any studies must actually have documented vaginal atrophy, as demonstrated by three medical criteria:

1. A vaginal pH greater than 5

2. A thin vaginal wall

3. Bothersome symptoms, such as painful intercourse

For a product to prove efficacy, three changes must be met after 12 weeks of treatment:

1. Vaginal pH must decrease to less than 5

2. The vaginal wall must become thicker

3. The initial bothersome symptom (such as painful sex) must be reduced

In addition, the products must also prove to be safe. Often the FDA requires far longer than 12 weeks of use to ensure safety, since treatment of vulvovaginal atrophy generally takes place not over weeks or months but over years. While we are on the topic of safety, let’s talk about that product insert that essentially makes you feel like it would be prudent to update your will before you start to treat your vaginal dryness.

FDA class labeling requires all products with the same ingredient to have the same warning, even if it has never been demonstrated in that product. For example, in some circumstances, taking systemic estrogens can increase the risk of developing a blood clot. That risk has never been demonstrated in the use of a local vaginal estrogen product; nevertheless, the FDA requires that warning to be on every product that contains estrogen. In fact, every single one of the warnings on local vaginal estrogen labels is based on the risks associated with systemic oral estrogen. Not one single complication listed on the package insert has ever been shown to result from using vaginal estrogen. Currently there is a movement among scientists to get these dire warnings off the label since there is no evidence of truth to them and many women who would benefit from using vaginal estrogen are too frightened to do so.

All of the following FDA-approved local vaginal estrogen products have met the same safety and efficacy criteria. While there are differences among them, usually the decision as to which product to use comes down to personal preference or, sometimes, finances.

Vaginal Estrogen Creams

There are currently two FDA-approved vaginal estrogen creams. Estrace contains a plant-derived 17-beta estradiol. Premarin contains conjugated estrogens derived from horse urine.

Research has shown that, with systemic hormone therapy estrogens, there seems to be an advantage to a plant-derived estradiol product over conjugated estrogens. As far as vaginal estrogen creams are concerned, however, there doesn’t seem to be any significant difference in efficacy or safety between the two. Many women object to the treatment of the horses that are used to manufacture Premarin and for that reason prefer the plant-derived therapy.

How to Use Vaginal Creams

Creams come in a toothpastelike tube. You squeeze the cream into a reusable applicator, insert the applicator into the vagina, and use a plunger to release the cream. The typical recommended dosage is one-half to one full applicator. Women who prefer not to use the applicator can put a strip of cream on their finger and insert their finger in their vagina. This way is environmentally friendly, and there’s no applicator to wash and reuse!

Advantages of Creams over Other Vaginal Estrogen Products

Creams are generally the least expensive form of vaginal estrogen, since they have been around for a long time.

Another advantage is being able to control the amount you use. You can taper the amount of cream you insert to determine the lowest amount you need to get results. This is important, since the recommended amount of estrogen cream results in blood levels that are slightly higher than those with other vaginal estrogen products. Many of my patients require only a tiny amount of vaginal estrogen to keep things lubricated and elastic. It doesn’t take much.

While cream is intended to be used inside the vagina, a major advantage to the cream is that it can also be applied directly to the opening or outside of the vagina to help reverse thinness and dryness of external tissues such as the vulva, vestibule, and clitoris.

Disadvantages of Creams over Other Estrogen Products

Creams tend to be messy. They tend to “drip” out of the vagina. The reusable applicator, while environmentally friendly, has to be washed after every use. You also need to measure the cream as you load the applicator. Most women find estrogen cream to be a lot less convenient than other products, even though they pack a slightly stronger estrogen punch.

The Vaginal Estrogen Ring: What Is It?

Currently there is only one low-dose vaginal ring, Estring, a soft, flexible, nonlatex ring that contains 7.5 micrograms of a plant-derived beta estradiol.

How to Use It

Estring sits in the vagina and must be replaced every three months. Kind of like the filter in your Brita. One size fits all, and unlike a diaphragm, this ring does not need to fit a certain way. You simply fold the flexible two-inch ring and give it a little push so that it slips into the back of the vagina. Once it is in, you will not feel it or be aware of it in any way. It does not need to be removed during intercourse (although you can if you want to), and it is the rare guy who can feel it.

Advantages of the Ring over Other Vaginal Estrogen Products

Convenience, convenience, convenience. There is no dripping cream, and no applicator to wash. You only need to think about this product four times a year.

Disadvantages of the Ring over Other Estrogen Products

An internal ring offers some of the external benefit of estrogen creams, but not as much. Also, you cannot control the amount of estrogen being delivered the way you can with estrogen creams. The ring is expensive, and not every insurance plan will cover it. Some women just don’t like having something inside their vagina all the time, and some have difficulty putting it in place, then taking it out. I do have a handful of patients who come in and have me do it for them, but only rarely. Most patients who try the ring like it and continue to happily use it.

Vaginal Estrogen Tablets

Vagifem is a vaginal tablet that contains 10 micrograms of plant-derived beta estradiol. This tiny tablet (about the size of a baby aspirin) comes preloaded on a slender disposable applicator. You insert it a few inches into the vagina, push the plunger, and throw away the applicator. The tablet magically sticks to the wall of the vagina and slowly dissolves. It sticks so well that you can insert it anytime. Even if you go for a brisk walk just after inserting it, you will not find your vaginal tablet sticking to the toe of your shoe!

Advantages of Tablets over Other Vaginal Estrogen Products

Like the ring, vaginal tablets offer a consistent dose of estrogen. There is no mess with tablets and no applicator to wash—in fact, most women find tablets to be the easiest product to use. You can also taper the dose by using it less often. Vagifem delivers the lowest dose of all the vaginal estrogens. That doesn’t make it any safer (they are all equally safe), but for women who desire the lowest dose of estrogen, this is the one.

Disadvantages of Tablets over Other Estrogen Products

Like the ring, vaginal tablets primarily deliver internal benefits. There is some external benefit, but some women find that they still need external help. Environmentally conscious women don’t like that the applicator is disposable. Also, with tablets you have to remember to insert one every few days. Unlike the ring, you can’t “set it and forget it.”

Which Vaginal Estrogen Product Works Best?

Again, studies show that every single estrogen product on the market works equally well. All are safe. All normalize vaginal pH. All restore the vaginal walls to premenopause status so that intercourse is comfortable. All help with bladder symptoms and eliminate irritation and odor. Your decision as to which product you choose is completely based on personal preference, convenience, ease of use, and, in many cases, what your insurance will cover. It’s not unusual for someone to start with one product and find that she prefers another.

The Best of Both Worlds

I find that many of my patients need a combination approach when it comes to vaginal estrogen. I advise them to use the ring or the tablet to get rid of the internal sandpaper feeling and apply estrogen cream on the outside once or twice a week to increase the elasticity of the external tissues.

When treating external tissues, you should apply a dab of estrogen cream using your fingers once a day, focusing on the opening of the vagina and the vestibule. Once normal elasticity is restored (usually after about two weeks), once or twice a week is generally adequate for maintenance.

Here are some more questions you may have:

How Often Do I Need to Use a Vaginal Estrogen?

If you are using a cream or tablet, you need to use it every night for 14 days (the “repair” part of the treatment). Twice weekly is recommended for maintenance if you use the cream or tablet, but I find that many of my patients do just fine if they use it only once a week. Some need to use it twice a week, and I have the occasional patient who is dry unless she uses it three times a week. The key is consistency! If you stop your estrogen treatment, it doesn’t take long for atrophy to set in again. In other words, skipping your estrogen for months and then deciding to use it the night before you leave on a cruise is not a good plan. Vaginal estrogen products are not lubricants—they restore lubrication.

How Quickly Will I See Results?

Within two to four weeks of initiating estrogen therapy, most women are able to have comfortable intercourse. In fact, a look at vaginal tissue under a microscope shows that normal thickness is often restored to the vaginal walls in that amount of time and the tissue is indistinguishable from premenopausal vaginal tissue. Some women need a longer “repair” time, and the effects are cumulative.

Many women are reluctant to try a local vaginal estrogen. But once they do, they rarely stop.

How Much Estrogen Is Absorbed into My Body?

When you use vaginal estrogen, the amount of hormone that is absorbed into your bloodstream is minuscule, and even though it sounds counterintuitive, the longer you use it, the less estrogen gets absorbed.

You read that right. Dry, thin vaginal walls are like tissue paper, so when estrogen is first applied, it doesn’t stay in the vagina but seeps right through and gets absorbed into the bloodstream. Within a short time of starting therapy, the thin vaginal tissue thickens enough that the estrogen stays in the vagina instead of getting absorbed into the bloodstream. If you measure blood estrogen levels in a woman who routinely uses small amounts of vaginal estrogen, her levels would be no higher than the normal postmenopausal range. That’s great news for the woman who is concerned about any risks that might be associated with using estrogen.

The amount of systemic absorption of estrogen in a year of using the vaginal tablet Vagifem is the same as if you took two oral estrogen tablets a year.

In the case of the ring and vaginal tablets, levels are essentially in the same range that you would find in menopausal women who do not use vaginal estrogen. The cream does have a slightly greater absorption rate than the ring or tablets. Since women use highly variable amounts, serum levels are variable as well.

Are There Ever Systemic Side Effects?

It is possible in the first couple of weeks, when absorption of vaginal estrogen is slightly higher, to have some systemic side effects. In the first two weeks, remember, you are using Vagifem tablets every night, the Estring releases a little more estrogen when it is first placed, and vaginal creams are more absorbed at the start of use. Some of my patients note a little breast tenderness or some alleviation of hot flashes at the onset of using these medications. Stick with it and the breast tenderness will go away. Don’t get too excited if your hot flashes are diminished, because that will probably not last either.

What Changes Can I Expect?

Local vaginal estrogens reverse essentially every one of the genital changes that occur when estrogen levels go down. The increased blood flow will cause the vaginal tissues to thicken and have a pinker appearance, and it will also improve the ability of those tissues to heal if there is a scratch or tear. Lubrication will increase. Elasticity and rugae will return, and the vagina will be able to expand and accommodate even a jumbo penis. (You should be so lucky!) The increase in collagen fibers will make external vulvar skin thicker. In short, your vagina and vulva will be as they were prior to menopause. Well, not exactly. Your pubic hair will still be sparse and gray.

Most women think that if they are not having intercourse, there is no reason to use vaginal estrogen. Think again! Fewer bladder infections, less urinary urgency, less odor, less irritation, and fewer vaginal infections are all really good things.

Local Estrogen: True or False?

You name it, I’ve heard it. So, for the record: If you use vaginal estrogen, your husband will not grow breasts, you do not need to abstain from intercourse for 24 hours, and no, the cream should not be used at the time of intercourse. The biggest myth is that you cannot use a local vaginal estrogen product if you have breast cancer or are at risk for breast cancer (see chapter 16). Then there’s the question about using a little on your face to eliminate the wrinkles where you don’t want them. I’m not allowed to answer that one. (Smile.)

How Long Can I (or Should I) Continue to Use Vaginal Estrogen?

Estrogen does not accumulate over time. The blood level of estrogen in a woman who has been using local estrogen for two years is the same as it is in the woman who has been using it for ten years. So that recommendation that you might have heard about using estrogen at the lowest amount for the shortest period of time? That doesn’t apply to vaginal estrogen. In fact, the North American Menopause Society (NAMS) recently proclaimed that “Vaginal Estrogen Therapy should be continued as long as distressful symptoms remain.” Not only is there no time limit, but you need to remember to consistently use it since, if you stop, it’s pretty much a guarantee that the dryness will return.

So, you can use vaginal estrogen as long as you’re interested in having intercourse and maintaining vaginal health—in other words, until death. Women in their eighties can still enjoy intercourse. The real challenge is finding a partner who is still “good to go.”

Do You Know?

Forty-two percent of women are not aware that local estrogen prescriptions are available, and only 7 percent of women seeking treatment for sexual problems are offered a prescription to relieve any of their symptoms. Most never fill it.

Local Estrogen Alternatives

Some women have been told not to use a local vaginal estrogen for various medical reasons, or they simply prefer not to. Many of those women will see similar results from using a long-acting vaginal moisturizer. (Refer back to chapter 5 for information on buying the right product!) Another strategy is to initially use a local estrogen to treat atrophy, and then continue with a long-acting moisturizer for maintenance.

Ospemifene

Ospemifene (Osphena) is a daily pill to be taken by mouth. (Now that you know some pills are taken by vagina, I need to be specific!) This pill is not estrogen but is classified as a SERM, or selective estrogen receptor modulator. SERMs are drugs that either block estrogen pathways or activate estrogen pathways in specific tissues. SERMs used to be called “anti-estrogens,” but since they can have either estrogen-like or anti-estrogen-like activity, that term is no longer used. Tamoxifen is a SERM that blocks estrogen pathways in the breast, which is why it is useful in the prevention of breast cancer. Raloxifene is another well-known SERM that activates estrogen pathways in bone (to treat osteoporosis) but blocks estrogen pathways in the breast (to prevent breast cancer).

Ospemifene activates estrogen pathways in vaginal tissue to lower pH, thicken vaginal tissue, and alleviate painful intercourse from vaginal atrophy. It essentially has the same effect as local vaginal estrogen. Further good news—ospemifene activates estrogen receptors in bone and blocks estrogen receptors in breast tissue!

Ospemifene does weakly stimulate the tissue that lines the uterus, but there is no evidence that this will increase the risk of uterine cancer. Of course, any woman, whether she takes ospemifene or not, should evaluate any postmenopausal spotting or bleeding. About 7 percent of women have a few more hot flashes when using this product. Women with breast cancer are advised not to use this drug, not because there may be problems with it for them, but because it hasn’t yet been tested in women with breast cancer. In fact, since ospemifene blocks estrogen receptors in breast tissue, most experts feel that it is the perfect option for the woman with breast cancer. It has even been shown to shrink breast tumors in rats! It is also ideal for the 50 percent of women who, according to the 2013 Revive survey, prefer to swallow a pill than to put something in their vagina.

Like local estrogen, ospemifene is not a cure-all, and many women will still need to use a lubricant or a long-acting vaginal moisturizer with this medication. But since only 7 percent of the 32 million women who need help with painful intercourse are getting it, another option is always a welcome addition.

Vaginal DHEA

Vaginal DHEA (didehydroepiandrosterone) is one of the most promising products soon to arrive (hopefully!) in your neighborhood pharmacy. DHEA is the precursor hormone to estrogen and testosterone that is naturally secreted by the adrenal glands in low amounts. DHEA decreases by roughly 60 percent at menopause and continues to decline over time. DHEA is often recommended to enhance libido, but what many women don’t appreciate is that multiple well-designed scientific studies have proven that vaginal DHEA can reverse vaginal dryness in menopausal women as well as vaginal estrogen does. Daily intravaginal DHEA improves pH, thickens vaginal walls, and decreases pain during intercourse. DHEA supplementation appears to be safe and does not stimulate breast or uterine tissue.

Currently, vaginal DHEA ovules can be obtained only by prescription in a compounding pharmacy. Dosages vary but are generally in the neighborhood of 0.25 milligram a day twice a week.

What About Vaginal Testosterone?

You know by now that the standard hormonal treatment for vaginal dryness is local estrogen. This makes sense since we know that vaginal tissues are loaded with estrogen receptors in desperate need of fuel to function and that local vaginal estrogen, for most women, alleviates this problem.

While testosterone has long been recognized as an essential requirement for an intact libido, we now also understand that vaginal and vulvar tissues are rich in testosterone receptors that play a role in normal lubrication. Some sexual health experts are now treating vulvar and vaginal atrophy with a combination of estrogen and testosterone, and preliminary studies indicate that the combo works much better than either hormone alone. If you are still dry despite local estrogen therapy, you may want to consider the addition of a compounded testosterone to get things slippery.

Your Cheat Sheet for a More Slippery Sex Life After Menopause

I’ve given you a lot of information, and I know it’s confusing. Clearly, there are a lot of tools out there to alleviate vaginal dryness and pain—lubes, moisturizers, local estrogens, DHEA, ospemifene, systemic estrogens, pelvic physical therapy, dilators. Where to begin?

It really depends on the severity of your issues. There is a huge difference between the woman who says, “Gee, it doesn’t feel as wet as it used to,” and the woman who hasn’t had anything even approach her vagina for 20 years because it was so excruciatingly painful the last time she tried. What follows are some general guidelines—and the heart and soul of the book.

Group 1: Mild Dryness

I can have intercourse, and sometimes it’s okay, but more often than not it feels a little dry and scratchy. Sometimes it really hurts.

Apply a generous amount of lubricant to the outside of your vagina and all over his penis. If intercourse is pain-free and pleasurable, there is no need to do anything else other than having frequent intercourse. And have plenty of lube on hand.

Some women find that even if a lubricant works, they don’t want to use one just at the time of intercourse and would rather do something that will keep things wet and ready to go anytime. If that’s your preference, try a long-acting vaginal moisturizer, a local vaginal estrogen product, ospemifene, or vaginal DHEA. You are not required to have severe atrophy to be prescribed one of these solutions.

Group 2: Lube Isn’t Doing the Job

The lube helps a little, but only a little. I’d rather just skip sex instead.

In spite of making things slippery, lube is not enough if your vaginal tissue is thin and has lost its elasticity. You need to start with either a long-acting moisturizer or a medication to get the tissues in shape. If you want to try a local estrogen product, DHEA, or ospemifene, you will need to see your doctor to get a prescription. No matter which product you choose, use it for at least 14 days before you attempt intercourse again.

Use a lubricant even if you are using a long-acting moisturizer or prescription product. In one study, 40 percent of women discontinued using their local estrogen product because “there wasn’t enough relief.” Just because you are using estrogen doesn’t mean you don’t also need a lube.

If things are fine once he is inside but the entry still feels tight and dry (and if the lubricant doesn’t help), use a vaginal estrogen cream on the outside daily for two weeks, and then taper to one to two times per week.

If intercourse is pain-free and pleasurable, great. Do not stop using the moisturizer or prescription product! I guarantee you that things will get dry again if you do. You are not suddenly going to start making estrogen.

After a few months, it is fine to increase the time between doses. If your atrophy is not severe, and most important, if you are having intercourse on a regular basis, some women are able to use the local vaginal estrogen only once a week or the long-acting moisturizer only once a week. That is great—not because it is safer, but because it is cheaper and more convenient. But if you taper down to once a week and things start to get dry, obviously you need the estrogen and/or moisturizer twice a week and there is no getting around it.

Group 3: Things Are Bad . . . Really Bad

He can’t even get it in there. Cleaning toilets sounds infinitely more appealing than attempting intercourse.

There is no getting around it: you are going to need to get a prescription for a local vaginal estrogen product, DHEA, or ospemifene. Your vagina is broken and needs to be repaired. Don’t panic. Just get a prescription.

Before you try intercourse with an actual penis, start with dilators (remember chapter 6?). Once you are successful with dilators, continue to work with them until you are able to get a dilator in that is slightly larger than the penis in your life. When you first attempt to have intercourse, use a generous amount of lubricant and be in a position that puts you in control if things are not going well. A warm bath beforehand will help relax you and your vagina.

If things are going well, keep using whichever product is keeping your tissues healthy. Twice weekly is recommended for maintenance if you use the cream or tablet, but I have the occasional patient who is dry unless she uses it three times a week. The key is consistency! It doesn’t work if you stop using your estrogen for months and then decide to use it on date night.

If you are not making progress with the dilators, if you are unable even to get a small dilator in, or if you are still having pain, you need to be evaluated by a gynecologist who can determine if the tissues are healthy, or if there is another issue going on. If everything checks out, you probably have pelvic floor pain and dysfunction from muscle memory and will need pelvic floor physical therapy.

I know you are frustrated, but this is fixable! It is just no longer a do-it-yourself project.

Use It or Lose It

Don’t underestimate the importance of having intercourse on a regular basis once vaginal elasticity is restored. “Use it or lose it” is one of those phrases that actually has some truth to it. If no ready or able partner is available, a toy is a good substitute, both for your own pleasure and to keep things alive until a priapic prince comes along!