Has sex literally become too much of a pain? Are you avoiding intimacy because what used to feel great now feels like razor blades on your insides?
You’re not alone! It’s estimated that up to 70% of women will experience a decline in vaginal health as they get older and hormones start to change.
This change can occur as early as age 35 or 40, but it is most common after age 45. Most women report vaginal dryness and reduced lubrication. Many have constant irritation, burning, itching, reduced elasticity, and even bleeding after intercourse. In addition, loss of sensation resulting in inability to orgasm, urinary leakage, and recurrent urinary tract infections are frequently reported. One of my patients, an avid equestrienne, had to stop riding until we were able to solve her chronic pain and burning.
The medical term for this is “vulvo-vaginal atrophy,” or VVA. It now falls poetically under the new name “the genitourinary syndrome of menopause,” or GSM.
There, I said it! Menopause, that thing no one likes to acknowledge or talk about, comes with several unwelcome surprises. GSM is one of the first things that starts to happen, along with mood swings, hot flashes, and night sweats.
You might be wondering how and why this happens. The main culprit is declining hormone levels, specifically estrogen. The cells in the vaginal skin and muscle respond to estrogen, and when levels of this hormone decline during the years leading up to and during menopause, these tissues begin to degenerate. The vaginal connective tissue (collagen, elastin, and smooth muscle) begins to lose strength. The skin of the vagina gets thinner and less stretchy, and it does not lubricate like it used to. Blood flow to the area decreases. The resultant decrease in stretchiness and natural lubrication makes sex difficult and painful.
There are other things that can also occur due to declining hormones. Loss of volume and thickness of the inner and outer lips, thinning of the pubic hair, changes in pH causing more vaginal infections, decreased pelvic floor strength and control, and decreased bladder capacity and loss of bladder control can make you feel like the most unsexy version of yourself right when you should be celebrating your mature, self-confident, and wise womanhood.
Fortunately, it can be successfully treated! Women have a variety of options for treating GSM. There are non-hormonal, hormonal, and energy-based therapies currently available. Some are commercially available at a retail pharmacy, others are made by compounding pharmacies, and a few (but not many) are FDA approved for treating GSM. Most women do best with a combination approach tailored to their specific symptoms and lifestyle.
Topical or intra-vaginal non-hormonal therapies include over-the-counter lubricants and moisturizers. Due to the thinning of the vaginal mucous membrane, many women respond well to the ones containing HA (hyaluronic acid), which can plump up that skin. It works by acting as a humectant and helping to hold water in the tissue. This is usually applied regularly in the form of a suppository or serum to maintain hydration. Revaree by Bonafide and RevitalizeHer by JoyLux are two commercially available products I find helpful. Vitamin E is often an added ingredient. At the time of sexual activity, coconut oil can help and also happens to keep yeast at bay. Of course, there is always the option of non-silicone-based lubricants like Astroglide, too.
Systemic non-hormonal therapies include a prescription drug called Osphena. It falls into a category of oral medications called selective estrogen receptor modulators (SERMs), which mimic the desired effects of estrogen without using hormones. There is also a commercially available and FDA-approved vaginal suppository called Intrarosa that uses a hormone-boosting medication to promote estrogen production in the vagina. Natural DHEA suppositories act very similarly and can be compounded (in a compounding pharmacy) with things like Vitamin E, hyaluronic acid, and probiotics.
Hormonal therapies can be of great help! These can be administered orally, topically, vaginally, or via implanted pellets. They can be systemic (affecting the whole body) or used for a localized effect in the vaginal tissue only. There are two types of bio-identical estrogen that can be used: estradiol, which is more potent, and estriol, which is weaker but often used vaginally for GSM. Estradiol tends to have a more systemic effect even when used locally. Estriol can be given intra-vaginally in the form of creams or suppositories without affecting the rest of the body. Premarin, a brand-name hormone that comes in a commercially available cream, can be used vaginally for GSM. It is made from conjugated equine estrogens, so it is not bio-identical. Compounded bio-identical testosterone, which is an essential female hormone for energy and libido, can also be used vaginally to increase lubrication and sex drive.
Just like in facial and body applications, energy-based therapies can be helpful for vaginal rejuvenation. These devices activate the healing response in the body, creating new collagen, increasing blood flow, and restoring more youthful functioning. Laser resurfacing devices (diVa, Mona Lisa Touch) provide results in three to five sessions. Radiofrequency energy devices (ThermiVa, Viveve) use controlled heat application to rejuvenate the tissue and results can be achieved in one to two sessions. You can expect to have to repeat these treatments in two to three years to maintain results. Photobiomodulation, or light therapy, uses specific wavelengths of red and infrared light to heal the area and restore normal functioning. The JoyLux vFit Gold is a device you can purchase for home use that uses this technology.
Like I mentioned earlier, most women respond best when using a combination approach. For example, for milder symptoms I would recommend vaginal estriol and DHEA with the vFit Gold device. For more severe GSM associated with menopausal symptoms, I would recommend a laser or radiofrequency treatment along with systemic bio-identical hormone replacement therapy.
Have an honest conversation with your doctor about your concerns. There is no need to suffer when there are so many good options for treatment. That equestrienne patient I mentioned earlier? She is now back in the saddle and enjoying her life!
Angelou K, Grigoriadis T, Diakosavvas M, Zacharakis D, Athanasiou S. The Genitourinary Syndrome of Menopause: An Overview of the Recent Data. Cureus. 2020 Apr 8;12(4):e7586. doi: 10.7759/cureus.7586. PMID: 32399320; PMCID: PMC7212735.
Shim S, Park KM, Chung YJ, Kim MR. Updates on Therapeutic Alternatives for Genitourinary Syndrome of Menopause: Hormonal and Non-Hormonal Managements. J Menopausal Med. 2021 Apr;27(1):1-7. doi: 10.6118/jmm.20034. PMID: 33942583; PMCID: PMC8102810.
Lanzafame RJ, de la Torre S, Leibaschoff GH. The Rationale for Photobiomodulation Therapy of Vaginal Tissue for Treatment of Genitourinary Syndrome of Menopause: An Analysis of Its Mechanism of Action, and Current Clinical Outcomes. Photobiomodul Photomed Laser Surg. 2019 Jul;37(7):395-407. doi: 10.1089/photob.2019.4618. Epub 2019 Jun 17. PMID: 31210575; PMCID: PMC6648197.