Vaginal atrophy

Overview

Vaginal atrophy used to be a medical term for thinning and drying of the vagina's inner lining, often after menopause. Another name for it was atrophic vaginitis. These terms are no longer used. The physical changes they described are now considered to be part of a group of symptoms that affect the genitals and lower urinary tract, called genitourinary syndrome of menopause (GSM).

GSM happens when the body has less of the hormone estrogen. It can involve painful sex, a frequent or urgent need to urinate, and other distressing symptoms.

Having less estrogen doesn't mean you have to put up with the discomfort of GSM. Treatment can bring you relief.

When to see a doctor

Many people have GSM after they go through menopause, yet few seek treatment. Some people might feel embarrassed to talk with their healthcare professional about their symptoms. But it's important to get the help that you deserve.

Make an appointment with your doctor or other healthcare professional if you have:

• Light spotting or bleeding for no clear reason.
• Unusual fluid that comes out of the vagina.
• Burning or soreness.

Also make an appointment if you have painful sex that doesn't get better after you use a vaginal moisturizer (K-Y Liquibeads, Replens, Sliquid, others), water-based lubricant (Astroglide, K-Y Jelly, Sliquid, others) or silicone-based lubricant (ID Millennium, Pink, Pjur, others).

Risk factors

Certain factors may play a role in GSM, such as:

• Smoking. Cigarette smoking affects blood flow. Less blood and oxygen may reach the vagina and other nearby areas. Smoking also reduces the effects of the estrogen your body makes.
• No vaginal births. People who have never given birth through the vagina may be more likely to develop GSM symptoms than those who have had vaginal births.
• No sexual activity. Sex or masturbation boosts blood flow and makes tissues in the vagina more elastic.

Prevention

Regular sexual activity, either with or without a partner, may help prevent genitourinary syndrome of menopause. Sexual activity increases blood flow to the vagina, which helps keep tissues in the vagina healthy.

Treatment

To treat genitourinary syndrome of menopause, your healthcare professional might recommend that you first try a remedy you can buy without a prescription. If that doesn't help ease your symptoms, you may opt for a hormone treatment, other prescription medicine or a device to stimulate and stretch vaginal tissues, called a vaginal dilator.

Vaginal moisturizers or lubricants

As a first step, you might try one of these products to ease symptoms:

• Vaginal moisturizers. These products (K-Y Liquibeads, Replens, Sliquid, others) can help restore some moisture to your vagina. You may have to use the moisturizer every few days. Its effects tend to last a bit longer than those of a lubricant.
• Water- or silicone-based lubricants. You can use water-based (Astroglide, K-Y Jelly, Sliquid, others) or silicone-based lubricants (ID Millennium, Pink, Pjur, others) just before sex to ease pain and friction. Choose lubricants that don't contain glycerin or warming ingredients such as capsaicin. Your vagina may get irritated if you're sensitive to these. Stay away from petroleum jelly or other oil-based products for lubrication if you're also using condoms. These can break down latex condoms on contact.

Topical estrogen

This is also called vaginal estrogen. It's a lab-made version of the hormone that goes directly into the tissues of the vagina. Compared to estrogen taken by mouth, vaginal estrogen works at lower doses and limits your overall exposure to estrogen. That's because less of the hormone reaches the bloodstream. It also may provide better direct relief of symptoms.

Vaginal estrogen therapy comes in various forms. Because they all seem to work equally well, you and your healthcare professional can decide which one is best for you.

• Vaginal estrogen cream (Estrace, Premarin). You insert this cream into your vagina with a device called an applicator, usually at bedtime. Most often, you use it daily for 1 to 3 weeks, and then 1 to 3 times a week after that. But ask your healthcare professional how much cream to use and how often to insert it.
• Vaginal estrogen suppositories (Imvexxy). You place these low-dose estrogen treatments about 2 inches into the vagina daily for two weeks. After that, you insert them twice a week.
• Vaginal estrogen ring (Estring). You or your healthcare professional inserts a soft, flexible ring into the upper part of the vagina. The ring releases a steady dose of estrogen. It needs to be replaced about every three months. Many people like the convenience this offers. A different, higher-dose ring called Femring is considered a system-wide treatment rather than a topical one.
• Vaginal estrogen tablet (Vagifem, Yuvafem). You use an applicator to place this treatment in your vagina. Ask your healthcare professional how often to insert the tablet. For instance, you might use it daily for the first two weeks, and then twice a week after that.

Ospemifene (Osphena)

Taken daily, this pill can help relieve painful sex symptoms in those with moderate to severe GSM. Ospemifene is an option for women who have had a history of estrogen-dependent breast cancer.

Prasterone (Intrarosa)

These vaginal inserts deliver the hormone DHEA directly to the vagina to help ease painful sex. DHEA is a hormone that helps the body make other hormones, including estrogen. Prasterone is used nightly for moderate to severe vaginal atrophy.

Systemic estrogen therapy

Sometimes, vaginal dryness is linked with other symptoms of menopause, such as moderate or severe hot flashes. If you have all of these symptoms, your healthcare professional may recommend estrogen pills, patches or gel, or a higher-dose estrogen ring. Estrogen taken by mouth, or as a patch or gel onto the skin, enters your entire system. Ask your healthcare professional to talk with you about the risks and benefits of systemic estrogen. If you still have your uterus, you will need another hormone called progestin along with estrogen.

Vaginal dilators

These devices stimulate and stretch the vaginal tissues and underlying muscles to reverse narrowing of the vagina. You can use them along with estrogen therapy.

If painful sex is a concern, vaginal dilators may relieve discomfort by stretching the vagina. You can buy them without a prescription. But if your symptoms are very painful, pelvic floor physical therapy also may help. Your provider or a pelvic physical therapist can teach you how to use dilators.

Topical lidocaine

This prescription ointment or gel can ease pain from sex. You put it on the opening of the vagina 5 to 10 minutes before sex.

If you've had breast cancer

If you have a history of breast cancer, tell your healthcare professional and think about these options:

• Nonhormonal treatments. Try moisturizers and lubricants as a first choice.
• Vaginal dilators. These devices stimulate and stretch the tissues and muscles of the vagina. They don't add hormones to the body.
• Vaginal estrogen. Your cancer specialist, called an oncologist, can talk with your main healthcare professional about whether low-dose vaginal estrogen might help you. It may be an option if hormone-free treatments — such as moisturizes, lubricants and dilators — don't ease your symptoms. For most women, there's minimal risk with low-dose estrogen of breast cancer coming back.
• Systemic estrogen therapy. Systemic estrogen treatment generally isn't recommended, especially if your breast cancer was sensitive to hormones.

Self care

If your vagina feels dry or irritated, you may get relief if you:

• Try a moisturizer. Examples include K-Y Liquibeads, Replens and Sliquid. This can restore some moisture to your vagina.
• Use a water- or silicone-based lubricant. A lubricant can reduce pain during sex. Water-based products include Astroglide, K-Y Jelly and Sliquid. Silicone-based products include ID Millennium, Pink and Pjur.
• Give yourself time to become aroused during sex. The natural lubrication that happens when you get aroused can help reduce symptoms of dryness or burning.