It’s common. It’s painful. But nobody wants to talk about it – vaginal dryness and painful sex. But if you do have it, you’re not alone. Roughly half of women after menopause will have vaginal dryness or painful sex. Doctors call it Genitourinary Syndrome of Menopause or GSM.

Why Does it Happen?

The lower levels of estrogen that start occurring just before menopause begin affecting both the intimate tissues and the urinary tract. Though it can occur before, it often begins months to years after menopause. It can take that long for the lower estrogen levels to finally shrink and thin the tissues inside and just outside the vagina.

What Does it Cause?

Research has shown that not only is GSM uncomfortable or downright painful, it also negatively affects a woman’s sexual health, her relationships, and the quality of her life, and that can happen whether she is sexually active or not. It can also cause painful urination.

Why Doesn’t it Get Treated?

Even though it happens often, and even though there are many forms of treatment, only a small percentage of women ever get treated.

Why? Because doctors typically don’t ask about it, and most women don’t tell their doctors they are having this problem. Some women don’t realize there are treatments, some are too embarrassed to discuss it, some think there are no treatments, and some think it will embarrass their doctor.

When Does it Happen?

GSM can happen to any woman as she passed through menopause. But it is particularly common in women who have their ovaries removed while they are still menstruating. The sudden loss of estrogen can have a huge effect on the intimate tissues. Women who are being treated for cancer, especially breast cancer, may be treated with medications that inhibit aromatase, an enzyme that helps to produce estrogen in the body. In those women, estrogen levels are particularly low, and the discomfort and pain are often among the worst.

Are There Other Symptoms?

Lower estrogen levels also raise the vaginal pH, which reduces the “good” lactobacillus of the vagina. And that causes a pH imbalance in the vagina that can lead to a discharge.

Women with GSM may also notice that their labia or lips that surround the vaginal opening, and their clitoris begin to shrink in size. The opening of the vagina may narrow because low estrogen reduces the elastic tissue in the walls of the vagina. That can lead to the color of the vaginal walls getting paler and more sensitive.

What Else Could it Be?

There can be other things that can cause similar symptoms, like vaginal or urinary infections, or skin diseases of the vulvar tissues, taking chemotherapy, contraceptive pills or antidepressants. There can also be a condition called pelvic floor dysfunction or even malignancy in the tissues.

What Are the Treatments?

The main thing is to understand that once you realize there is a problem, get seen so you can get treated. First-line treatments include (Get all the details in The Estrogen Fix)

• Over-the-counter (OTC) non-hormone vaginal moisturizers before sex
• Vaginal moisturizers contain ingredients like polycarbophil or hyaluronic acid that can be used several times per week and help to keep moisture in the vagina.
• Use unperfumed soaps and washes around your vagina
• Spend more time on foreplay to help you feel more aroused

If those OTC remedies don’t do the trick, several FDA-approved prescription therapies are available.

• Low-dose vaginal estrogen therapy (ET) is available as creams, inserts, tablets, and ring, and all of these methods have been shown to be effective in clinical studies. The local ET makes you feel better because it thickens the tissues, improves vaginal blood flow, lowers vaginal pH, and increases vaginal lactobacilli. Although a very small amount of the estrogen gets absorbed into the blood, the amounts are very small. As you’ll see below, it is safe.
• Dehydroepiandrosterone or DHEA. The cells of the vaginal lining are able to metabolize the DHEA to testosterone and estrogen. An FDA approved daily vaginal insert is called prasterone. Because it begins as DHEA and not estrogen, it’s not required to have a Black Box warning saying it can cause breast cancer, so it is often prescribed for breast cancer survivors.
• Ospemifene, which is an oral medication called a selective estrogen-receptor modulator. It has been shown to improve painful sex due to GSM if a woman cannot or does not want to take vaginal estrogen. However, since it hasn’t been studied in women with breast cancer, it isn’t recommended for women in that situation

Some doctors worry that a little estrogen into the blood stream is a possible problem. But they don’t have to worry. Serum estradiol levels in menopausal women who use vaginal ET (2 mg vaginal ring, 10 µg vaginal tablets, or 4 and 10 µg vaginal gel cap) have blood estrogen levels within the postmenopausal range.

A 2016 Cochrane review of 30 randomized controlled studies found that FDA-approved local ET formulations can relieve symptoms without increased risk of endometrial hyperplasia after a year of use. Based on that information, women with a uterus don’t have to use a progestogen to protect the uterine lining if they use vaginal estrogen. However, if you do have uterine bleeding, it’s important to see your doctor.   

Neither the Women’s Health Initiative Study of 45,000 women nor the Nurses’ Health Study of 54,000 postmenopausal women found any increased risk of heart disease, breast cancer, stroke, pulmonary embolism, hip fracture, colorectal cancer, or death in women using vaginal ET.

Unfortunately, even though studies show it is safe to use, the FDA requires that the estrogen box for vaginal estrogen come with a “black box warning” (not supported by data on local ET). That’s one of the reasons so few women are prescribed local ET, though the ACOG published an opinion that there is no evidence that local estrogen increases the risk of either recurrence or death in estrogen receptor positive breast cancer patients. There is another treatment for painful intercourse due to GSM called.

What’s The Most Important Thing To Remember?

The most important things to remember is that GSM is common, affects quality of life, and many treatments are available. Talk about it with your healthcare provider – don’t suffer in silence.