Sex and Vaginal Health after Menopause: Without estrogen

  • After menopause the vaginal epithelium becomes thin.

  • This leads to a condition called atrophic vaginitis.

  • This can lead to:

    • Vaginal dryness​

    • Dyspareunia​ (painful intercourse)

    • Irritation of genital skin ​

    • Pruritus​ (itching)

    • Burning ​

    • Vaginal discharge

    • Reduced transudation through the vaginal epithelium and reduced cervical gland secretions

    • Deterioration of tissue, decrease in blood flow, loss of elasticity, decreased rugae, thinning of tissues and epithelium, and increased pH

    • Collagen fibers combine while elastin fibers divide in the dermal layer causing a loss of mucosal elasticity with a shortening and narrowing vagina

    • The thinning of tissues and epithelium in the vagina are a result of fewer squamous cells in secretions. The vaginal mucosa has reduced glycogen content and lack lactobacilli which convert glycogen into lactic acid to maintain a healthy vaginal pH in the range

    • As the volume and internal mucosa with inflammation, overgrowth of pathogens, and a resultant acidic environment decreases from various structures in the external genitalia, further reduction in secretions occur

Non Hormonal​ Therapies for Vaginal Health Include

  • Lifestyle modifications​

  • Moisturizers​

  • Natural​ therapies

  • Laser​

Hormonal ​Therapies

  • Estradiol​

  • DHEA​

Other and Experimental​Therapies

  • PRP​

  • Cannabis products

Lifestyle Modification

  • Sexual activity should be encouraged to maintain vaginal health.

  • Continued regular vaginal activity provides protection from atrophy, presumably by increasing the blood flow to the pelvic organs and maintaining vaginal elasticity and pliability

  • Women who participate in sexual activity report fewer symptoms of atrophy and have less evidence of shrinkage of the vagina and stenosis

 Vaginal Mositurizers

A moisturizer is a as a cream or lotion, used to restore moisture to the skin.

Popular vaginal moiturizers

Replens

  • Most common vaginal moisturizer available in the world

  • Polycarbophil-based vaginal gel that binds to vaginal epithelial cells and maintains hydration.​

  • Hydrophilic​

  • Water-insoluble but water- swellable cross-linked polymer that forms a thin layer of film over the cells and remains adherent to the epithelial cell surface for 24–72 h, releasing purified water to hydrate the underlying cells​

  • Sloughed off with epithelial cell turnover​

  • Results in improvement in: vaginal fluid volume​, moisture and ​elasticity ​

  • The pH of the gel is 3.0 and it buffers to a normal vaginal pH of 3.5–5.026.

  • Two clinical trials documented that Replens has a beneficial effect equivalent to topical vaginal estrogen therapy ​

  • Both therapies exhibited statistically significant increases in vaginal moisture, vaginal fluid volume, and vaginal elasticity, with restoration of the premenopausal vaginal pH state. ​

  • Studies have found that both Replens and placebo water soluble lubricant substantially ameliorated vaginal dryness and dyspareunia, although the positive effect of Replens on dyspareunia was significantly higher

  • In addition, animal studies showed that treatment with Replens improved the histological features on biopsies from vaginal epithelium. 

  • Additives of concern in Replens include: parabens​, petroleum products​, silicone products​, polypropylene glycol​, sodium hydroxide​, chlorhexidine, phenoxyethanol​, fragrance​, glycerin​, palm oil

Top selling mositurizers with additives of concerns

  • K-Y® Liquibeads: silicone oil, glycerin, dimethiconol​

  • Replens™ Long Lasting Vaginal Moisturizer: glycerin, palm oil, methylparaben, sodium hydroxide​

  • Vagisil® ProHydrate™: glycerin, ethylhexylglycerin, sodium hydroxide​

  • Luvena® Restorative Vaginal Moisturizer: Multiple PEGs​

  • HYALO GYN® Vaginal Hydrating Gel: propylene glycol, sodium hydroxide

Lubricants

  • During sexual arousal, a woman’s vagina typically becomes lubricated, making it wetter and ready for sex. Many women find that lubrication makes sex more comfortable or enjoyable because it reduces friction and irritation.

  • Many times women experience vaginal dryness and lack of lubrication due to loss of estrogen.

  • A lubricant is a liquid or gel that women and their partners can apply during sex to make the vulva, vagina, or anal area wetter.

  • There are several types of lubricants, each with advantages and disadvantages. 

  • Water-based lubricants are usually inexpensive and easy to find. They also wash off easily. However, they may not last as long as a couple would like and may need to be reapplied during sex to maintain moisture.

  • Silicone-based lubricants tend to last longer than water-based lubricants. However, they do not rinse as easily and irritate some women if they aren’t rinsed immediately after sex.

  • It’s important to note that water- and silicone-based lubricants may contain glycerin, which can lead to inflammation and yeast infections. If this becomes a problem, lubricants without glycerin are available.

  • Oil-based lubricants should be used with caution. These lubricants cannot be used with latex condoms, as they will weaken the latex, making the condom more likely to leak or break.

  • Petroleum-based lubricants, such as those made from petroleum jelly, mineral oil, or baby oil, cause irritation or inflammation for some women.

Popular Vaginal Lubricants and Additives of Concerns

  • K-Y® Jelly Personal Lubricant: glycerin, chlorhexidine, methylparaben, sodium hydroxide​

  • Astroglide® Liquid Personal Lubricant: glycerin, propylene glycol, methylparaben, propylparaben​

  • Astroglide® Natural: phenoxyethanol​

  • Shibari Personal Lubricant: glycerin, methylparaben, propylparaben

  • Lush® Water Personal Lubricant: glycerin, propylene glycol, methyparaben, PEG-90M​

  • Lulu Lube: propylene glycol​

  • Pre-Seed™ Personal Lubricant: methylparaben, propylparaben​Surgilube®: propylene glycol

Natural therapies​

  • Coconut oil​

  • Almond or apricot kernel oil​

  • Vitamin E oil​

  • Compounded therapies

  • Yes Products

    • Yes (The Yes Yes Company Ltd, Alton, Hants, UK) is a water-based lubricant and mositurizer containing a mixture of plant polymers that hold and carry water, coat the vaginal epithelium and release water into it

    • The moisturizing effect continues for 48–72 h. ​

    • The pH matches the normal premenopausal vaginal pH. ​

    • Water-based ingredients

      • Aloe barbadensis (aloe vera), Cyamopsis tetragonolobus (guar gum), Ceratonia siliqua (locust bean gum), Linum usitatis- simum (flax extract), phenoxyethanol, potassium sorbate, xanthan gum, and citric acid. ​

    • Oil-based ingredients

      • Prunus dulcis (sweet almond) oil, Butyrospermum parkii (shea butter), Helianthus annuus (sunflower) seed oil, Theobroma cacao (cocoa) seed butter, Cera alba (beeswax), and natural tocopherols (vitamin E).

 The Mona Lisa Laser

  • The Mona Lisa Touch Laser system was FDA cleared as safe to use

  • it has not been specifically FDA approved for treatment of atrophy, laxity, or incontinence. ​

  • This is an "off-label" use of a device which has been used in a medical setting in thousands of women. ​

  • In September 2014, the SmartXide2 CO2 laser from the Italian company DEKA, along with a CO2 laser from the American company Cynosure, were cleared by the US Food and Drug Administration (FDA) for "incision, excision, vaporization and coagulation of body soft tissues in medical specialties including aesthetic (dermatology and plastic surgery), podiatry, otolaryngology (ENT), gynecology, neurosurgery, orthopedics, general and thoracic surgery (including open and endoscopic), dental and oral surgery and genitourinary surgery. 

  • Symptom Improvement % after three Mona Lisa Touch treatments:​

    • Burning 84%  report improvement​

    • Itching 85% report improvement​

    • Dryness 76% report improvement​

    • Painful intercourse 74% report improvement​

    • Laxity 90% report improvement 

PRP (platlet rich plasma)

  • 20 postmenopausal breast cancers survivors ​

  • Administered intra-mucosal injections of PRP combined with HA (Regenkit) and performed clinical evaluations at 0, 1, 3, and 6 months. ​

  • All participants showed improvement in the clinical symptoms of vaginal dryness and dyspareunia. ​

  • No adverse events were reported.

Cannibas products may be helpful for some

Methods to Improve Vaginal Capacity

  • Education. Patients may need to learn more about their pelvic anatomy and how different components work alone and together. They may also need to learn how habits or hygiene affect their symptoms.

  • Pelvic floor exercises. Patients are taught how to contract and relax pelvic floor muscles in relation to other muscles. They are also taught breathing and timing techniques to make the exercises more effective. Such exercises can stretch tight muscles, strengthen weak ones, and improve flexibility.​

  • Manual therapy. A physical therapist may use hands-on massage or stretching to help with posture, blood circulation, and mobility.​

  • Pelvic floor biofeedback. Biofeedback is a technique that can help patients “see” how the pelvic floor muscles are working. To do this, a probe is inserted into a woman’s vagina or a man’s anus and results are displayed on a computer screen.​

  • Electrical stimulation. A low voltage electrical current may be used to teach patients how to coordinate their muscle contractions.​

  • Vaginal dilators. These tube-shaped plastic devices can help women learn to relax their pelvic muscles to allow easier penetration. Women who have been treated for gynecological cancer may also find them helpful for vaginal rehabilitation after treatment.

Vaginal Dilators

Graduated vaginal dilators are used to evaluate vaginal size and elasticity and also as a therapeutic tool for women who are unable to have intercourse because of tight, tense pelvic floor muscles or vaginal reduction due to menopause, radiation therapy, chemotherapy and/or surgery.

Often, vaginal dilator therapy is a part of pelvic floor physical therapy.

Vaginal dilators have two purposes.

  • To get the vagina used to having something inside of it. Even if the size of your vagina is normal, painful sex initiates a cycle of pain–fear–muscle spasm–more pain that results in the vagina constricting at any attempt to have intercourse.

    • Dilators are often needed after the initial cause of the pain has been eliminated to erase muscle memory that has kept your pelvic floor in protective mode.

    • By starting small and then increasing gradually to whatever penis size is in your life, the vaginal tissues and pelvic floor muscles “learn” to accommodate having something inside without a pain response being triggered.

  • A vaginal dilator is also a way to gently and gradually stretch tissues that are tight and have lost their elasticity, which is often the case if a woman has vaginal dryness and thinning from hormonal changes, skin conditions (such as lichen sclerosis) or her vagina has been altered by radiation or surgery.

    • Scarring and shrinkage of the vaginal opening is almost always reversible

  • The other important advantage to using a dilator is that you will know when you are ready for intercourse.

Dilator Usage

Step 1: Start with a warm bath (to relax you and your pelvic floor muscles) and make sure you have at least 15 minutes of privacy.

Step 2: Lie in bed on your back with your knees bent and slightly apart. Be comfortable. Use pillows to support your head and back.


Step 3: Apply a generous amount of lubrication to the opening of your vagina and to the tip of the smallest dilator. If your dilator is silicone, be sure to use a water-based lubricant. 

Step 4: Bear down slightly and gently slide the dilator in as far as it will comfortably go.


Step 5: If there is no pain or resistance, continue to sequentially insert larger dilators. The dilator that should be used to initiate your therapy is the dilator that does not cause pain with insertion but does create some resistance or slight discomfort when you insert it.

Step 6: Once you get to the size that causes some resistance, leave it in place for 5 to 15 minutes. Concentrate on letting your vaginal tissues relax around it. Your buttocks and thighs should be relaxed as well. Don’t forget to breathe.

Step 7: Repeat steps 1 through 6 on a daily basis, if possible. Don’t panic, however, if you miss a day.


Step 8: When you are at the point where the dilator you’re using slides in without resistance or discomfort, it is time to go up to the next size. This can takes days...or weeks.

Step 9: When you are ready to go up to the next size, always use the smaller dilator to start your session for at least a few days before you insert the next size. 

  • Wash your dilators with antibacterial soap and water and dry them well before you put them away.

  • When first using a dilator, a little spotting is not unusual, but you should never experience severe pain or heavy bleeding. If you do, or if you are unable to comfortably insert a dilator, see your doctor before proceeding.

  • Sometimes it is necessary to coat the dilator with local anesthetic jelly (you will need a prescription for this). In other cases, a muscle relaxant is useful.

Summary

  • Vaginal atrophy, or thinning is very common after menopause

  • It can lead to painful sexual activity

  • The treatment of vaginal atrophy can include vaginal estrogens and DHEA for some women

  • Some women may not be candidates for topical hormone treatment, or desire to avoid its usage

  • The treatment of vaginal atrophy to improve vaginal health should include:

    • Vaginal moisturizer

    • Vaginal lubricant

    • Vaginal dilator usage

    • Maintain healthy vaginal pH through probiotics

    • Maintain excellent hydration

    • For some women pelvic floor physical therapy may be helpful

    • For some women intravaginal valium and baclofen may be helpful

Recommended Resources

Hyalo Gyn

A hyaluronic acid based lubricant

Healthy Choice Apothecary

A compounded hyaluronic acid

YES VM - Water-Based Vaginal Moisturizer

YES WB - Organic Water Based Personal Lubricants

YES OB - Natural Plant Oil Based Personal Lubricant

Soul Source Dilators

Vaginal Probiotic

Rephresh Vaginal pH lowering gel