Patient information: Vaginal dryness

VAGINAL DRYNESS OVERVIEW

Vaginal dryness, also known as atrophic vaginitis, is a common condition in women. Although it is most common in women who are postmenopausal, vaginal dryness can occur in women of any age.

Some women have uncomfortable symptoms of vaginal dryness, such as pain with sex, burning vaginal discomfort or itching, or abnormal vaginal discharge, while others have no symptoms at all.

Fortunately, there are several effective treatments for vaginal dryness. If you think you have vaginal dryness, talk to your healthcare provider about which treatment is right for you. (See "Clinical manifestations and diagnosis of vaginal atrophy".)

VAGINAL DRYNESS CAUSES

Estrogen helps to keep the vagina moist. Vaginal dryness occurs when the ovaries produce a decreased amount of estrogen. This can occur at certain times in a woman's life, and may be permanent or temporary. Times when less estrogen is made include:

• As you near menopause or after menopause.
• After surgical removal of the ovaries, chemotherapy, or radiation therapy of the pelvis for cancer.
• After having a baby, particularly if you breastfeed.
• While using certain medications, such as tamoxifen, danazol, medroxyprogesterone (Provera® or DepoProvera®), leuprolide (Lupron®), or nafarelin. When these medications are stopped, estrogen is produced normally again.

Cigarette smoking also affects the moisture in the vagina, and can make vaginal dryness worse.

VAGINAL DRYNESS TREATMENT

There are two treatment options for women with vaginal dryness: moisturizers/lubricants and vaginal estrogen. All vaginal dryness treatments work temporarily. The vaginal dryness will return when the treatment is stopped unless the ovaries make more estrogen.

Vaginal moisturizers and lubricants — Vaginal moisturizing agents and vaginal lubricants can be purchased without a prescription. These products do not contain any hormones and have virtually no side effects.

Lubricants are designed to reduce friction and discomfort from dryness during intercourse. The lubricant is applied inside the vagina or on the penis just before having sex. Products designed as vaginal lubricants, such as Astroglide® or KY® Silk-E are more effective than lubricants that are not designed for this purpose, such as petroleum jelly (Vaseline®). As well, petroleum jelly can damage the latex used in condoms and diaphragms. Hand and body lotions should not be used to relieve vaginal dryness since they can be irritating to vaginal tissues.

Hand and body lotions should not be used to relieve vaginal dryness since they can be irritating to the vaginal tissues. Petroleum jelly (Vaseline®) is not recommended because it can damage the latex used in condoms and diaphragms.

Natural lubricants — Natural lubricants, such as vegetable oil or saliva, are easily available products that may be used as a lubricant with sex. Oil-based products are not recommended for use with condoms or diaphragms; the oil can damage the latex, potentially making it less effective in preventing pregnancy or sexually transmitted infections.

Vaginal estrogen — Vaginal estrogen is the most effective treatment option for women with vaginal dryness. Vaginal estrogen must be prescribed by a healthcare provider.

Very low doses of vaginal estrogen can be used when it is put into the vagina to treat vaginal dryness, and little to no estrogen is absorbed into the bloodstream. As a result, there is a much lower risk of side effects, such as blood clots, breast cancer, and heart attack, compared with other estrogen-containing products (birth control pills, menopausal hormone therapy).

Several types of vaginal estrogen products are available:

• Estrogen cream (eg, Premarin®, Estrace® cream) is inserted into the vagina every day for two to three weeks, and then one or two times weekly. The cream can be messy and is therefore usually used at bedtime. In addition, the recommended dose of estrogen cream is higher than needed to restore the vaginal tissue to normal. Many experts feel that the lower dose vaginal estrogen tablets or ring are a better option.
• The vaginal estrogen tablet (Vagifem®) is a small tablet that must be inserted inside the vagina. The tablet is packaged in a disposable applicator. Vagifem is usually taken every day for two weeks and then twice weekly.
• The vaginal estrogen ring, called Estring®, is a flexible plastic ring that is worn inside the vagina all the time. It is replaced every three months by the woman or her healthcare provider. The ring does not need to be removed during sex or bathing. It cannot be felt by most women or their sexual partners.

Estring releases the smallest amount of estrogen of any vaginal estrogen product, and should not be confused with the estrogen replacement vaginal ring (Femring®), which releases a higher dose of estrogen and is intended to relieve hot flashes. (See "Patient information: Postmenopausal hormone therapy".)

How long can I use vaginal estrogen? — Vaginal estrogen is thought to be safe and can probably be used indefinitely, although there are no long-term studies confirming its safety.

Is vaginal estrogen safe for women with a history of breast cancer? — The safety of vaginal estrogen in women who have a past history of breast cancer is unclear. A small amount of estrogen can be absorbed from the vagina into the bloodstream. If you have a history of breast cancer, talk to your healthcare provider or your oncologist about the potential risks and benefits of vaginal estrogen.

Sexual activity — Vaginal estrogen improves vaginal dryness quickly, usually within a few weeks. You may continue to have sex as you treat vaginal dryness because sex itself can help to keep the vaginal tissues healthy. Sexual activity (including masturbation) may help the vaginal tissues by keeping them soft and stretchable and preventing the tissues from shrinking.

If sex continues to be painful despite treatment for vaginal dryness, talk to your healthcare provider. (See "Causes and treatment of sexual pain disorders".)

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Postmenopausal hormone therapy

Professional Level Information:
Chronic and acute causes of vaginal discharge other than bacterial vaginosis, candidiasis, or trichomoniasis
Clinical manifestations and diagnosis of menopause
Clinical manifestations and diagnosis of vaginal atrophy
Treatment of vaginal atrophy
Causes and treatment of sexual pain disorders

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/ency/article/002142.htm)

• The Hormone Foundation

      (www.hormone.org/public/menopause.cfm, available in English and Spanish)

[1-3]