On Vaginal Dryness and Painful Sex in Menopause

Question from Amy:

“My question is can you please talk about postmenopausal vaginal dryness and pain during sex? I’ve never had it before, had a pretty easy menopause, but those two things are really kicking my butt. And they definitely lower my libido because having that experience of the dryness or the pain, you know, just makes it less appealing. So I would love to hear what you have to say about that.”

Question from Anonymous:

“I would love for you to comment on menopause and painful sex. I really do not have any interest in going on hormone replacement therapy. I’m about two years post-menopausal. And in general I’ve had really bad experiences with hormones and birth control and all of that in the past. I’m really healthy, I have a plant-based diet, I exercise, I get great sleep, I don’t have any hot flashes, no digestion issues. And the only thing that I would be willing to try is maybe the estrogen cream. But I really can’t find a straight answer on how much of that ends up in your bloodstream. Or if you have any other recommendations and suggestions to help with painful sex, that would be awesome. Moisturizers and the standard things I come across do nothing for me. It’s really affecting my relationship and my life. I dread sex and don’t enjoy it at all.”

Amy and Anonymous – thank you for these questions. I want to honor how courageous it is to ask a question that so many women have, about symptoms so many women struggle with – but all too often, embarrassed and in silence, and also too often just ‘put up with it’ to the detriment of their own physical comfort – or just say screw it and give up on sex! And just for the record, making this episode applicable to more than just menopausal years women, vaginal dryness and other causes of painful sex don’t just occur in menopause; nearly 20% of younger women (as young as 18 years old!) experience vaginal dryness, and many experience painful sex, too. So whether you’re in your menopausal years, you’re a practitioner – or just have a vagina – listen/read on. 

Today we’re going to focus in detail on the ‘vaginal dryness in menopause’ parts of your questions – what you need to know about causes, and what you can do to soothe and heal your vaj, make sex comfortable again, and even restore some juiciness to your arid netherlands so they aren’t never-lands for you! 

In future episodes we’ll swing back to low libido from other causes in an upcoming episode, and we’ll also have upcoming episodes on all-things hormone replacement therapy (HRT) so you can understand the pros – and the cons – so you can make your best decisions – though I will talk about topical hormones and their specific role in vaginal dryness; you'll have that option in your vaj-health bundle so should you want  – or feel you need – to go in that direction, you’re knowledgeable about all the options you have to choose from. And it is your choice! 

Before I dive into this topic I want to shout a few things from the rooftops:

• Menopause is a natural and powerful phase in our lives – and a major whole-woman transition with a lot to integrate emotionally, physically, spiritually. 
• Even though menopause brings with it symptoms for many women,  menopause is neither a disease state nor a state of hormone deficiency.
• There is a wide-range of natural and medical options at your disposal for menopausal symptoms, so you do not have to suffer in silence. 
• You can have the best sex of your life during and after menopause – and that’s not just me telling you this – there are abundant studies that prove this fact! 

Okay, let’s get to it! 

What Causes Vaginal Dryness and Painful Sex in Menopause? 

For most women, internationally, the average age of natural (ie non-medically or surgically induced) menopause is 52 years old, with perimenopause beginning as many as 8 years prior.  

Sometime in these years leading up to this shift, our levels of the potent form of estrogen, called estradiol, begin to decline and once we’re in menopause, defined as a year and a day past the very last period you’ve had, we produce predominantly a milder form of estrogen, called estrone, along with us continuing to produce testosterone and lower levels of progesterone.

Not only does this shift in estrogen types and levels herald a major change in our phase of life, but for many women, this shift is accompanied by a variety of symptoms from sleep troubles and mood swings, to hot flashes, low libido, and vaginal dryness, which, in turn, may be accompanied by pain during or right after sex. 

This is because estradiol is responsible for:

• Maintaining vaginal thickness and elasticity 
• Keeping the vaginal surfaces moist 
• Maintaining optimal genital blood flow 
• Maintaining a healthy vaginal microbiome 

Hands down, the most common cause of painful sex in menopause is vaginal dryness, both of which are part of a potential constellation of symptoms called  “genitourinary syndrome of menopause” (GUSM), due to this natural decline in estradiol levels. 

It’s nature’s way of saying we’re past our fertile and potential-for baby-making years, and onto a womb of our own.

Women with GUSM may experience any or all of the symptoms: 

• Vulvovaginal dryness 
• Decreased vaginal lubrication during sexual activity 
• Pain during sex
• Vulvar or vaginal bleeding (eg, postcoital bleeding, labial fissures) 
• Decreased arousal, orgasm, or sexual desire 
• Vulvovaginal burning, irritation, or itching
• As well as urinary symptoms: urgency, painful urination, and recurrent urinary tract infections

To make sure we’re all on the same page here, your vulva is all the outside lady parts  you can see if you hold up a mirror down there, and your vagina is the tube that extends up inside. If you don’t know these terms – you’re not alone – but please do get clit-erate – I mean literate – about your body because it’s important for a whole host of reasons from personal pleasure to describing symptoms and getting proper medical care if needed. You can learn all about your lady parts here. 

The technical term for when things are dry down there is vulvovaginal atrophy; I don’t think this term is very kind or all encompassing, and it sounds permanent, which it does not have to be because there are effective therapeutic approaches you can take. But for the sake of accuracy, I’m using it. 

It’s not just natural menopause that can cause vaginal atrophy and with it vaginal dryness and painful sex. Other causes include:

• Surgical menopause (bilateral oophorectomy)
• Premature ovarian insufficiency
• Temporary decline is estrogen levels during the postpartum period or lactation
• Hypothalamic amenorrhea 
• Anti-estrogenic drugs
• Other medications may not cause atrophy but can also cause vaginal dryness, including antihistamines, for example. 

While GSM is the most common cause of vaginal dryness and painful sex after menopause, other conditions to be aware of that can cause vaginal discomfort and pain with sex for menopausal and postmenopausal women include:

• Vulvovaginitis: Most commonly caused by candida, bacterial vaginosis (BV), or a sexually transmitted infection such as trichomoniasis, gonorrhea, or chlamydia. Approximately 75% of women will develop symptomatic vulvovaginal candidiasis at least once in their lives. NAMS: “In postmenopause, an increase in candida infection has been associated with the use of HT and systemic diseases such as diabetes mellitus (DM) and immunodeficiency states.”
• Inflammatory conditions: i.e. Lichen sclerosus, Lichen planus, and Lichen simplex chronicus 
• Dermatitis: from possible irritants found in vaginal lubricants and moisturizers, soaps, detergents, panty liners, spermicides, scented toilet paper, etc. 
• Vulvodynia: Defined as vulvar pain of at least 3 months’ duration without a clear identifiable cause, this woefully understudied condition may affect as many as 8.3% of women, less than half of whom sought treatment and only 1.4% had been diagnosed.

If you’re not reasonably certain that your symptoms of vaginal dryness or pain with sex are due to menopausal changes, if symptoms have a sudden onset, are severe, or are accompanied by vaginal odor, pain outside of having or recently having had sex, or if there is vaginal bleeding, be sure to have a provider do a thorough exam/history to rule out other possibilities, as these conditions also have effective therapies that can relieve your discomfort. 

It’s Not Just YOU, But It Can Really Affect Your Life

If you think you’re alone in this, guess again! It’s estimated that at least 50 percent of postmenopausal women have some amount of vaginal atrophy as a result of decreased estrogen levels. One US study found that 57% of sexually active women aged 40 to 65 reported at least one symptom, like vaginal dryness or pain with sex. In another survey, nearly half of menopausal women experienced vaginal discomfort, most commonly vaginal dryness (85%) and pain during intercourse (52%). 

Not only are vaginal dryness and painful sex common, but they very commonly affect women’s sense of well-being! In that survey, 80% of participants said vaginal discomfort negatively impacted their lives, particularly with regard to sexual intimacy (75%), ability to have a loving relationship (33%), and overall quality of life (25%). Women further reported that it made them feel old (36%) and affected their self-esteem (26%). 

Additionally, healthy vaginal tissue acts as a barrier to infection – and not to be scary here – but this is really important ladies: Irritated, sore, cracked, dry vaginal tissue makes us more susceptible to sexually transmitted infections (STIs), including HIV. Keeping your cooch moist and healthy also helps to restore that protective barrier. You may be single or otherwise entering into new sexual partnerships or having sexual encounters and you might be thinking, ”Well, I’m not fertile anymore so who needs condoms? Stop right there: Happy healthy vulvar and vag tissue or not – You still do! 

Help at Your Fingertips

Okay, yes, that’s a joke – we do apply some of these remedies with our fingertips. But there’s a lot more to preventing and treating dry, irritated vaginal tissue, reversing vaginal dryness and thus making sex more comfortable, than hormones – though those can be used, too. There’s a panoply of wonderful 100% safe practical options to try, there are herbs and supplements, and one tip that may surprise you! 

That said, an estimated 6,000 U.S. women reach menopause every day (over 2 million per year).and according to one frequently cited survey, an average of 27 million women between the ages of 45 and 64, or 20% of the American workforce, experience menopause symptoms each year. Additionally, about 5% of women experience early menopause between the ages of 40 and 45. As such we’re a veritable goldmine for companies seeking to profit from our discomfort. While some may offer helpful solutions, many of the companies now overpopulating the marketplace with solutions are offering false hope and exaggerated claims in the form of bottles of pills and tubes of lubes. 

Let’s Start with Effective, Easy, and Practical Tips for Vaginal Dryness and Painful Sex

Your vulva and vagina are self-cleaning so to avoid irritation and also damaging your precious vulvovaginal microbiome ecology:

• Clean the vulva with water only
• Use mild soaps for bathing, without applying it to the vulva
• Pat the vulva dry after bathing and apply a preservative-free emollient (eg, vegetable oil or plain petrolatum) topically to retain moisture and improve barrier functions
• Rinse the vulva with cool water (you can keep a peri-rinse bottle inyour bathroom) after urination and pat dry instead of wiping
• Wear 100% cotton underwear (and no underwear at night)
• Avoid vulvar irritants (perfumes, dyes, shampoos, detergents) and never douche.
• If you’re perimenopause and are still menstruating, switch to 100% cotton menstrual pads (if regular pads are irritating) and avoid tampons which absorb moistuer from your vaginal wall

Also 

• Use adequate lubrication for intercourse/vaginal penetration
• Apply cool gel packs to the vulvar area after sex for comfort if you feel irritated or uncomfortable
• Check with your medical provider about medications you might be on that can cause or contribute to vaginal dryness (for example, antihistamines) and whenever possible, avoid unnecessary antibiotic use to prevent damage to your vaginal flora ecology.

And remember to keep your tissue healthy by eating plenty of good quality fats in your daily diet including EVOO, avocados, nuts and seeds, and staying hydrated by drinking enough water! This is also great for your heart and brain health – and an added bonus is healthy fats and adequate hydration keep your skin healthy, toned, and prevents excessive wrinkling!

Lubes, Moisturizers, and CBD, Oh My

There are effective over-the-counter options you can try first that may be helpful, especially for mild symptoms. There’s also no shortage, as I mentioned, of folks who are going to try to sell you the latest and greatest product with sensational claims for improved vaginal health and well – sensation. Many of these products, even those marketed as ‘natural’ may contain additives like perfumes, flavors, spermicides, dyes, warming agents, and botanical extracts, which can be irritating to sensitive vaginal tissue. So it may take some trial and error to find one that works for you.

Topical products can be divided into lubricants, moisturizers, and natural oils. They do not contain hormones, so they do not have an effect on the vagina’s thickness or elasticity. Vaginal moisturizers can be used every 2–3 days as needed. Lubricants can be used each time you have sexual intercourse.

Before we explore the topical, non-hormonal options you can try, please note that oil-based products shouldn’t be used when you’re relying on latex condoms for birth control (if you’re still menstruating or aren’t sure you’re menopausal yet) or STI prevention, as they can cause breakage in the condoms (which might not be visibly obvious, either).

Lubricants can be water, silicone, or oil-based, and may be helpful in reducing friction during sex. They are designed to be applied before sex and don’t last very long.

Moisturizers are bioadhesive, so they stay on the vaginal tissue and are longer-acting than lubricants. They’re applied on a regular basis, typically every 1 to 3 days, to help retain moisture.  

An increasingly popular ingredient in both lube and vaginal moisturizers is hyaluronic acid (HA) – a component of our skin with impressive water-attracting properties that have made it a star hydrating active ingredient in a variety of skin care products. It’s also one of the few ingredients that actually has some research behind it: 

• One study found that a hyaluronic acid vaginal moisturizer was as effective as a water-based one with polycarbophil.
• A recent systematic review concluded HA has efficacy similar to vaginal estrogen in treating vaginal atrophy.
• Randomized studies comparing HA to vaginal estrogen head-to-head have found similar improvements in symptoms, though some suggest that HA may not be as effective as estrogen in normalizing the vaginal microflora.

Natural oils, like coconut oil, can be used as both lubricants and moisturizers. While there’s been little research on using coconut oil for vaginal dryness specifically, studies have shown that it is effective as a moisturizer in other conditions that cause dry skin, like atopic dermatitis. Many of my patients find it helpful. 

What about CBD/THC oils and suppositories? There are numerous products on the market, and studies that do suggest that oral use may be helpful for a number of painful gynecologic conditions including endometriosis, period pain. A recent survey found that over 60% of women with chronic pelvic pain from endometriosis, vulvodynia, interstitial cystitis or urinary chronic pelvic pain (IC/UCPP), and/or irritable bowel syndrome have used CBD orally. But I’ve yet to find studies on CBD or THC oils for the relief of vaginal dryness or painful sex due to vaginal dryness. It is possible that oil-based products may provide relief due to lubricant and moisturizing effects, or that there may be anti-inflammatory, vasodilatory effects, or pain relieving effects, but these have not been studied for these menopausal symptoms. That said, products that are scent- and irritating-ingredient free may be reasonable to use as oil-based topicals.

Topical lidocaine: The North American Menopause Society includes, amongst their recommended treatment options, the topical application of lidocaine to the vulva as a numbing agent before penetration as an option for women for whom sex is painful. I’ve never used this and while I’m not opposed, I do have to say that my team and I found this approach a little unnerving (so to speak). It is an option, it’s your body, and you get to make the rules – no judgment from me, and it may be a stop-gap option if you don’t want to use hormone therapy and aren’t getting enough relief from other recommendations herein. But I’d be remiss not to say that I feel conflicted about suggesting women numb sensation in order to have sex, and I also feel that if your body is saying ouch – it’s better to heal first.

Weirdly, Having Sex Can Help

Okay, I told you there would be a surprising tip! Here it is, as counterintuitive as it might seem if sex is uncomfortable: sex can help.

Regular sexual stimulation (alone or with a partner) promotes blood flow and the natural secretions that keep the vagina healthy. If not painful, penetration (with a partner or a vibrator or another sex toy) helps maintain vaginal vaginal width, length, and tone. 

But if penetration is painful, then please –  find non-penetrative methods for pleasure while doing the healing on your tender vulvar or vaginal tissue. Nobody should have to have sex that hurts! If you’re with a partner, talk with him/her/them about your needs, what works and what’s off limits at least for now, and what they can do to support you (go slowly, avoid deep penetration, more loveplay before or instead of penetration, non-penetrative ways to create pleasure and satisfaction). 

Pelvic floor physical therapy (PT) can also be helpful. It often involves (gently and at your pace!) using vaginal dilators, starting with a small one that fits inside comfortably and gradually increasing the size over time.  If this sounds weird, cringy, or intimidating, note you learn to do this for yourself! I only recommend female  providers for female clients! 

Herbs and Supplements

I wish, as an herbalist and Integrative MD, that I could say there’s a wealth of data on herbs and supplements for vulvovaginal dryness – but the data is fairly scant. That said, there are traditionally used herbs and herbal lubricants that my patients have benefited from over my 35 years in practice in women’s health and herbal medicine. For example, I’ve shared my recipe for a topical oil that can be applied with your fingers or made at home into the form of a suppository. It includes coconut oil and cocoa butter as a base, with calendula oil and optionally other herbs for healing  and moisturizing tender tissue. 

I frequently turn to Vitex (Chaste Berry, Chaste Tree),  a phytoestrogenic herb that has also been shown to increase progesterone and possibly estrogen  levels, for my menopausal patients because it’s been shown to be effective for hot flashes and vasomotor symptoms of menopause. A recent review of the literature suggests that at 4 mg/day over 16 weeks, Vitex may also improve vaginal tone, increase vaginal lubrication, make intercourse more comfortable, and may improve libido. 

Pueraria mirifica: You might hear of this herb so I want to share pros and cons. Traditionally used as a vitality enhancer and rejuvenating agent particularly for ‘older women,’ one study found that after 12 weeks of oral intake of this this herb (in capsules), healthy postmenopausal women aged 45 to 60 experienced alleviation of vaginal dryness symptoms and pain with sex and improvement in signs of vaginal atrophy with restoration of the atrophic vaginal tissue. That the pro. But the con is that while based on limited early evidence, this herb does appear promising and effective for menopausal symptoms, there is currently no evidence to show that it is safer than estrogen replacement therapy (ERT), and because it is far more difficult to standardize the amount of estrogen in it, may even be less safe. It’s a great example of how natural isn’t always safer than the conventional option. And that doesn’t mean not to try it – but I would discuss it more fully with your medical provider, and only use it fully aware of the risks until there’s more research. 

Anyone at risk for, or with a history of estrogen or progesterone receptor cancers should use caution and speak with their medical provider before using phytoestrogenic or progesterone increasing botanicals. Also, while they are typically not contraindicated for use with topical hormone therapies, I do not recommend combining them with oral hormone therapies. 

When it comes to supplements, the data is similarly limited. 

Oral vitamin D and vaginal vitamin E have been proposed, but efficacy data are limited and study findings are often discordant. 

Oral and vaginal probiotics to alter the vaginal microbiota could possibly be beneficial for treatment of symptoms of GSM, but comprehensive trials are needed for validation. 

Hormonal Approaches

While I know that most of us would prefer to avoid medications whenever possible, and that hormone therapy may understandably be high on your list to stay away from, Low-dose vaginal estrogen can consistently been found to be the most effective treatment for moderate to severe symptoms of vaginal atrophy not responsive to non-hormonal intervention. It restores vaginal blood flow, decreases vaginal pH, and improves the thickness and elasticity of vulvovaginal tissues. In other words, it can give you a big sigh of relief, and they can be effective in just a weeks after starting use, though can take 2 t0 3 months to begin to see maximum benefits. Low-dose estrogen often helps with urinary symptoms associated with menopause too: reduction in the incidence of urinary tract infections and overactive bladder symptoms.

While low-dose vaginal estrogen products are required to have a black box warning for safety, these warnings may overstate potential risks, discouraging their use.

When it comes to low-dose vaginal estrogen, there are a number of different  formulations you can try:  rings that stay in the vagina for a few months, tablets that are placed there and replaced every few days, and creams applied topically up to a few times a week. 

To answer Anonymous’s question: While some estrogen is absorbed through the vagina into the bloodstream (one study found this to be about 3% of the total amount in the preparation), the level of systemic absorption is lower than with oral or transdermal estrogen and blood levels in users are the same of only slightly higher than in the average woman after menopause. 

In one small study women received 0.3 mg conjugated estrogens daily orally and then vaginally. While systemic levels did rise with the vaginal dose, the vaginal dose resulted in a third lower serum estradiol and estrone levels than the same dose given orally. Concentrations after the vaginal therapy were “within or slightly above the normal postmenopausal reference range.”

According to NAMS, “Given minimal systemic absorption, women with a history of CVD or estrogen-responsive cancers may be candidates for low-dose vaginal ET if non-hormone options are ineffective. Discussion with a woman’s cardiologist or oncologist before initiating treatment is advised.”

While our anonymous caller said she’d be open only to estrogen cream, according to NAMS, the tablet or ring might actually be the better options if she has concerns about systemic absorption. They report that “In women for whom systemic HT is contraindicated, use of the estradiol vaginal tablet or low-dose estradiol vaginal ring generally is preferred to the use of estrogen creams because of their fixed-dosing and well-documented lack of significant systemic absorption.”

It’s important to recognize, however, that there are no long-term randomized trials evaluating the safety of low-dose vaginal estrogen use, though long-term observational data has not shown any increased risk of breast or endometrial cancer, coronary heart disease, stroke, or venous thromboembolism. 

Intravaginal use of the hormone dehydroepiandrosterone (DHEA) is also an option, as is an oral option called ospemifene, a SERM (selective estrogen receptor modulator), a drug that acts like estrogen on some tissues but blocks the effect of estrogen on other tissues.

Please Don’t Let Yourself Suffer

In my practice, whenever possible, I start with commonsense and the safe, natural approaches for a few months before progressing to hormonal therapies; but if a woman is really struggling, has tried everything and is still uncomfortable or suffering, I do think that having a happy, healthy vagina outweighs the risks of short-term or intermittent use of hormones for women at low risk when using them. I think of this as the new medicine for women – we get to pick what approach is best for our health and our lifestyles, using what’s safest and escalating to medical therapies when needed – but not creating dichotomies that prevent us from using what helps us feel our best. 

Too often, women simply go untreated, live with the discomforts of vaginal dryness, and just decide to tolerate – or forego – sex.  

In a survey mentioned earlier, 37% of women with symptoms of GSM did not consult any healthcare professional, and 40% waited one year or more before doing so. And although 78% used some form of treatment, this consisted mainly of lubricating gels and creams (65%); only 34% of women had used any form of hormone therapy. 

Why?

• Some women may not be aware that their symptoms are a treatable problem and instead see them as an inevitable part of aging.
• Many may feel uncomfortable discussing sexual issues with their provider, particularly but not only when the provider is male
• 70% of medical doctors report having received no training in supporting women in menopause with their common symptoms, and most medical  practitioners don’t effectively elicit information from their patients – if they ask at all – about vaginal and sexual symptoms – because they, too, are often uncomfortable and haven’t been adequately taught to do so
• Due to lack of knowledge, perceptions about the costs of specific therapies, and fears, misconceptions, and lack of knowledge about how to prescribe hormone therapies for women in menopause, medical practitioners  may  recommend less expensive, less effective, or over-the-counter therapies which may improve mild symptoms, but which don’t address low estrogen in women who would benefit most from hormonal therapy. 

But there are so many things you can try to restore comfort, ease, and pleasure in our bodies and lives – and also prevent problems like infection from dry, irritated vaginal (and urinary) tissues. 

Please don’t suffer by living with untreated vaginal dryness, pain with sex, or giving up on sex that you otherwise want because it hurts. This is a phase of our lives that is – in my opinion as a women’s health MD and menopause expert- meant to be filled with empowerment, self-love, and, when desired, sexual pleasure. Wishing you lots of Vitamin P – pleasure, that is. 

See you next time!