One of the most common complaints I hear from women going through menopause is sexual discomfort “sex hurts.” The vagina and vulva are estrogen sensitive areas of the body. As estrogen levels decline in menopause, a number of changes occur. The vaginal pH increases and this can result in more infections, commonly urinary tract or bladder infections. The vaginal walls are thin and fragile so they can tear with friction. The tissue can also become less moist and distensible. Some women can experience irritation or itching of the vagina and vulva. This is termed “atrophic vaginitis.”
Fortunately, this problem can generally be treated successfully. Vaginal moisturizers or lubricants are helpful to some extent. But a low dose topical formulation of estrogen has a greater impact because it can reverse the changes. Topical estrogen comes in the form of creams or a suppository (Vagifem) used two to three times a week at bedtime, or a vaginal ring (Estring) that can be left in place for three months. These local estrogen formulations are generally very safe. Only a minimal amount is absorbed systemically, and in fact, as the vaginal walls thicken, even less is absorbed. Most women start to see improvement within a few weeks but it can take a few months to achieve maximal benefit.
Some women prefer not to use vaginal preparations or find them messy or bothersome to insert. The Food and Drug Administration just approved a new drug to treat the vulvar and vaginal changes in menopause. This medication, ospemifene, marketed as Osphema, is taken orally once a day. It is a tissue selective estrogen agonist/antagonist, meaning it enhances estrogen activity in certain tissues and blocks it in others. Ospemifene improves the vaginal wall thickness and pH. However, as with known estrogen agonists/antagonists on the market, such as tamoxifen and raloxifene, it can increase hot flashes and may increase the risk of stroke. So, time will tell if this drug ends up being a viable option for the treatment of symptomatic atrophic vaginitis.
Genital discomfort from diminished tissue hormone levels during menopause is a common problem that is often undertreated. I encourage women to educate themselves on options available to them to improve their quality of life.