Patient education: Vaginal dryness (Beyond the Basics)
- Gloria Bachmann, MD
Gloria Bachmann, MD
- Department of Obstetrics, Gynecology & Reproductive Sciences
- Rutgers Robert Wood Johnson Medical School
- Richard J Santen, MD
Richard J Santen, MD
- Professor of Medicine
- University of Virginia Health Sciences Center
VAGINAL DRYNESS OVERVIEW
Vaginal dryness, also known as atrophic vaginitis, is a common condition in postmenopausal women. This condition is also common in women who have had both ovaries removed at the time of hysterectomy.
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 genitourinary syndrome of menopause (vulvovaginal atrophy)".)
VAGINAL DRYNESS CAUSES
Estrogen helps to keep the vagina moist and to maintain thickness of the vaginal lining. 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:
●At the time of menopause.
●After surgical removal of the ovaries, chemotherapy, or radiation therapy of the pelvis for cancer.
●After having a baby, particularly in women who breastfeed.
●While using certain medications, such as danazol, medroxyprogesterone (brand names: Provera or DepoProvera), leuprolide (brand name: Lupron), or nafarelin. When these medications are stopped, estrogen production resumes.
Women who smoke cigarettes have been shown to have an increased risk of an earlier menopause transition as compared to non-smokers. Therefore, atrophic vaginitis symptoms may appear at a younger age in this population.
VAGINAL DRYNESS TREATMENT
There are several treatment options for women with vaginal dryness: vaginal moisturizers or lubricants, vaginal estrogen, a pill called ospemifene (brand name: Osphena), and a vaginal tablet called prasterone, or dehydroepiandrosterone (DHEA). All vaginal dryness treatments work temporarily. The vaginal dryness will return when the treatment is stopped unless the ovaries make more estrogen.
Vaginal lubricants and moisturizers — Vaginal lubricants and moisturizers 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 sexual intercourse. The lubricant is applied inside the vagina or on the penis just before having sex. Products designed as vaginal lubricants (eg, Astroglide) are more effective than lubricants that are not designed for this purpose, such as petroleum jelly (Vaseline).
Oil-based lubricants, such as petroleum jelly, baby oil, or mineral oil, may damage latex condoms and/or diaphragms and make them less effective in preventing pregnancy or sexually transmitted infections. Polyurethane condoms can be used with oil based products. Also, lubricants that are made with water or silicone can be used with latex condoms and diaphragms.
Natural lubricants, such as olive, avocado or peanut oil, are easily available products that may be used as a lubricant with sex. Again, natural oils are not recommended for use with latex condoms or diaphragms; the oil can damage the latex, potentially making it less effective in preventing pregnancy or sexually transmitted infections.
Vaginal moisturizes (eg, Replens, Moist Again, Vagisil, K-Y Silk-E, and Feminease) are formulated to allow water to be retained in the vaginal tissues. Moisturizers are applied into the vagina three times weekly to allow a continued moisturizing effect. These should not be used just before having sex, as they can be irritating.
Hand and body lotions should not be used to relieve vaginal dryness since they can be irritating to the vaginal tissues.
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. A small amount of estrogen is absorbed into the bloodstream, but only about 100 times less than when using estrogen pills or tablets. 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 difficult to measure accurately and insert into the vagina.
●The vaginal estrogen insert (Vagifem) looks like a small tablet but is inserted inside the vagina. The vaginal tablet is packaged in a disposable applicator. Vagifem is usually inserted 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. In women who have previously had a hysterectomy, the ring will sometimes fall out.
Estring should not be confused with the estrogen replacement vaginal ring (Femring), which releases a much higher dose of estrogen and is intended to be absorbed into the body to relieve hot flashes. (See "Patient education: Menopausal hormone therapy (Beyond the Basics)".)
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.
Ospemifene — Ospemifene is a prescription medication that is similar to estrogen, but is not estrogen. In the vaginal tissue, it acts similarly to estrogen. In the breast tissue, it acts as an estrogen blocker. It comes in a pill, and is prescribed for women who want to use an estrogen-like medication for vaginal dryness or painful sex associated with vaginal dryness, but prefer not to use a vaginal medication. The medication may cause hot flashes as a side effect. This type of medication may increase the risk of blood clots or uterine cancer. Further study of ospemifene is needed to evaluate the risk of these complications. This medication has not been tested in women who have had breast cancer or are at a high risk of developing breast cancer.
Prasterone (dehydroepiandrosterone) — Prasterone, also known as dehydroepiandrosterone (DHEA), is also an option for women with vaginal dryness due to menopause. It comes in the form of a suppository that is inserted into the vagina once a day. Vaginal estrogen therapy is more commonly used than prasterone, because vaginal estrogen has been studied more thoroughly and the twice-weekly dosing may be more convenient. However, prasterone is a reasonable option for women who can't take estrogen or prefer to avoid it, but who can use other vaginal hormones.
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. Vaginal intercourse 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 "Differential diagnosis of sexual pain in women".)
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Uterine cancer (The Basics)
Patient education: Sex problems in women (The Basics)
Patient education: Atrophic vaginitis (The Basics)
Patient education: Dyspareunia (painful sex) (The Basics)
Patient education: Sjögren's syndrome (The Basics)
Patient education: Vulvar pain (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Desquamative inflammatory vaginitis
Clinical manifestations and diagnosis of menopause
Clinical manifestations and diagnosis of genitourinary syndrome of menopause (vulvovaginal atrophy)
Treatment of genitourinary syndrome of menopause (vulvovaginal atrophy)
Differential diagnosis of sexual pain in women
The following organizations also provide reliable health information [1-3]:
●National Library of Medicine
●The Hormone Foundation
- North American Menopause Society. The 2012 hormone therapy position statement of: The North American Menopause Society. Menopause 2012; 19:257.
- Bachmann G, Lobo RA, Gut R, et al. Efficacy of low-dose estradiol vaginal tablets in the treatment of atrophic vaginitis: a randomized controlled trial. Obstet Gynecol 2008; 111:67.
- Santen RJ, Allred DC, Ardoin SP, et al. Postmenopausal hormone therapy: an Endocrine Society scientific statement. J Clin Endocrinol Metab 2010; 95:s1.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.