Vaginal Atrophy And Sexual Intercourse

Vaginal atrophy is a complication of persistently low levels of estrogen, usually after menopause in elderly women. In vaginal atrophy (also known as atrophic vaginitis), the walls of vagina becomes thin, dry and inflamed, which makes it uncomfortable (or even painful) to engage in normal sexual intercourse. In poorly managed cases, atrophic vaginitis may lead to recurring vaginal infections, disturbing urinary symptoms and other related ailments.

"Genitourinary syndrome of menopause (GSM)”, is a more appropriate term that is often used by healthcare professionals instead of vaginal atrophy as vaginal and urinary symptoms often co-exist in this condition.

What Are Classic Symptoms Of Vaginal Atrophy?

The classic presentation of vaginal atrophy varies; depending upon the age of patient and severity of atrophic changes; most characteristic symptoms are:

• Dryness and burning sensation in vagina
• Discharge from vagina
• Itching in the genital region
• Burning sensation while passing urine
• Urinary urgency
• Urinary incontinence and frequent urinary tract infections
• Discomfort and poor lubrication of vagina during sexual intercourse
• Light vaginal bleeding after sex
• Shortening or tightening of vaginal canal which further makes it hard to engage in a satisfying sexual encounter

What Causes Vaginal Atrophy In Women?

As discussed previously, insufficient or declining levels of estrogen can lead to vaginal atrophy. Following are some factors which can lower estrogen levels; such as:

• Menopause
• Perimenopause i.e. years preceding menopause in which women experience irregularity in the monthly menstrual cycles, poof flow, abnormal rhythm etc.
• Surgical menopause i.e. menopause due to surgical removal of ovaries
• Radiotherapy of pelvis for the management of a malignant condition
• Chemotherapy

• Side effect of hormonal treatment for breast cancer

Treatment

Doctor may recommend following treatment options:

OTC Estrogen Products:

• Water based lubricant: Use water based lubricants instead of glycerin containing lubricants, as many women have sensitivity towards glycerin which may lead to irritation and burning sensation. These lubricants also help in decreasing the discomfort during sex. If you are using condoms during sex, then petroleum based lubricants should not be used because it breaks down the latex in condom (thereby reducing the efficacy of your birth control method).
• Vaginal moisturizer: Moisturizes also helps in bringing back some moisture to your vagina. It should be applied every two or three days as the effect usually lasts longer when compared to traditional lubricants. Hyalo Gyn and Vagisil Feminine Moisturizer are some excellent examples.

If symptoms are not improved with over the counter medications then various estrogen therapies can be utilized:

• Estrogens via oral route: The pros and cons of estrogen replacement should be discussed with a primary care provider before considering the oral therapy. If you have or ever had breast cancer then your doctor may advice alternative options. For example, women who have/had a history of hormone-sensitive breast cancer are not ideal candidates for systemic estrogen therapy. Non hormonal treatments like moisturizers and lubricants should be ideally considered as a first choice of treatment. If non hormonal treatments doesn’t improve your symptoms then doctor may prescribe low-dose vaginal estrogen.
• Systemic therapy of estrogen: Systemic estrogen therapy is given when other symptoms of menopause (such as hot flashes, depression etc.) are also experienced. If uterus is not removed surgically then a combination of progestin and estrogen is considered ideal as opposed to estrogen-only therapy. Systemic therapy is available in a number of formulations such as, patches, pills and estrogen rings.

Topical Estrogen:

There are various forms of topical estrogens which can prove very effective against vaginal atrophy.

• Estrogen creams: Vaginal creams are a bit messy but they provide relief faster as compared to other topical formulations. It is inserted in vagina via an applicator on daily basis for one to three weeks followed by one to three times application per week.
• Estrogen ring: A soft flexible ring containing estrogen releases a specific dose for a designated period of time. The ring is placed at the upper part of vagina and has to be replaced after every three months.
• Estrogen tablet: An estrogen tablet is inserted inside vagina via disposable applicator. The dosage and dosing frequency is usually decided after carefully assessing the risk profile and severity of results.

Alternative Treatment

Alternative treatments are trending these days. Although there are some alternate medicines for treating the dryness and irritation of vagina but you should ask your doctor before taking any supplements or herbal medication.

Self-management

The genitourinary syndrome due to menopause can be prevented if sexual activities are performed on regular basis either with partner or without partner. As blood flow toward vagina is increased during a sexual act, which helps in keeping the tissues healthy.

Speak to your doctor if vaginal atrophic changes are interfering with the quality of your sex life.

References

1. Kingsberg, S. A., Wysocki, S., Magnus, L., & Krychman, M. L. (2013). Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women's VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. The journal of sexual medicine, 10(7), 1790-1799.

2. Fernandes, T., Costa-Paiva, L. H., Pedro, A. O., Baccaro, L. F. C., & Pinto-Neto, A. M. (2016). Efficacy of vaginally applied estrogen, testosterone, or polyacrylic acid on vaginal atrophy: a randomized controlled trial. Menopause.

3. Portman, D., Shulman, L., Yeaw, J., Zeng, S., Uzoigwe, C., Maamari, R., & Iyer, N. N. (2015). One-year treatment persistence with local estrogen therapy in postmenopausal women diagnosed as having vaginal atrophy. Menopause, 22(11), 1197-1203.