Vaginal Changes At Midlife

One in two menopausal women report discomfort

Jeanne L. Alexander, MD

February, 2004

Researchers can't figure out one puzzling aspect of aging. Just under half of postmenopausal women seem unaffected by the dryness, burning or pain of thinning and ever-more-fragile vaginal tissues. Which means that sex for these women is still relatively normal. The vulva and the vaginal tissues need estrogen to retain their health and vitality. If estrogen levels dip, as they do after menopause, studies show it results in a range of unwanted side-effects.

Before menopause, a woman produces an average of 100 pg/ml of estrogen with a high in the 200's at the midpoint of her menstrual cycle. After menopause. this level usually drops below 50 pg and stays low.

While a low estrogen level appears to be a risk factor, however, it does not always predict dryness or sexual discomfort. Many women, even those with the lowest estrogen levels, still have no complaints. According to Dr. Philip Sarrel of Yale University, 43 percent of women with levels below 50 pg reported vaginal dryness while 57 percent did not.

Australian researcher Lorraine Dennerstein, MD, PhD, studied women three years after their menses had stopped and found that half reported increased vaginal dryness, yet the rest had no difficulty at all with lubrication or with intercourse. This underscores the different ways that women can respond to aging. Clinicians cannot generalize when treating post-menopausal patients.(Menopause, by definition, begins the year after menses has stopped.) The take-home point is that doctors need to view each patient as an individual.

Dr. Dennerstein found that only some women go on to develop pain with intercourse, and this problem, over time, increases in intensity or frequency. Still others have vaginal burning. This data was supported by Dr. Sarrel in the Yale Mid-life Study. The good news is that these symptoms can improve or reverse with topical hormone treatment, especially if they are caught early.

Finally, we must consider atrophic vaginitis, a clinical term for the aging of the vagina due to lack of hormones. We have no idea how many women have this problem because patients often fail to report it. They may be unfamiliar with this diagnosis or feel their symptoms aren't severe enough to mention. It's important to tell your clinician about any discomfort, since atrophic vaginitis can increase your susceptibility to vaginal infections as well as vaginal dryness.

Solutions for Vaginal Dryness

This problem can often be dealt with successfully by using over-the-counter lubricants such as Astroglide ®, Surgilube ®or Replens ®. Another way to solve the problem is to fix the cause. The glands which lubricate the vagina can be stimulated by local estrogen replacement. It is not necessary to give estrogen to the whole body when it can be delivered directly to the vagina by

• an estrogen cream applied with an applicator twice weekly
• a vaginal tablet called Vagifem ® administered twice a week
• a diaphragm-shaped ring, called the Estring ® that is worn continuously and releases estrogen for three months at a time.

These are a few examples of topical treatments for vaginal dryness currently available in the United States. We also have preliminary evidence that testosterone increases fluids in the vagina during sexual activity, but more studies are needed to confirm this.

If vaginal dryness is a problem, ask your doctor which solution is best for you. Some treatments require the addition of progesterone to protect the lining of the uterus from thickening. When using estrogen to restore lubrication, it is important to track your progress with your family practitioner or a gynecologist.

Many oncologists feel that the Estring ® vaginal ring is acceptable for women who have had breast cancer because there is minimal systemic absorption.

In future articles we will discuss the aging of the clitoris and its impact on the quality and robustness of orgasm, tightening of the vaginal canal and other aspects of normal aging.

General References

Berman, J. R., F. G. Almeida, et al. (2003). "Correlation of androgen receptors, aromatase, and 5-alpha reductase in the human vagina with menopausal status." Fertil Steril 79(4): 925-31. Abstract

Dennerstein, L., P. Lehert, et al. (2000). Biological and psychosocial factors affecting sexual functioning during the menopausal transition. Biology of Menopause. F. Bellino. New York, Springer-Verlag: 211-222.

Dennerstein, L., J. Randolph, et al. (2002). "Hormones, mood, sexuality, and the menopausal transition." Fertil Steril 77 Suppl 4: S42-8. Abstract

Gabrielsson J, Wallenbeck I, Birgerson L. Pharmacokinetic data on estradiol in light of the estring concept. Estradiol and estring pharmacokinetics. Acta Obstet Gynecol Scand Suppl. 1996;163:26-31; discussion 32-4. Abstract

Henriksson L, Stjernquist M, Boquist L, Cedergren I, Selinus I. A one-year multicenter study of efficacy and safety of a continuous, low-dose, estradiol-releasing vaginal ring (Estring) in postmenopausal women with symptoms and signs of urogenital aging. Am J Obstet Gynecol. 1996 Jan;174(1 Pt 1):85-92. Abstract

Kingsberg, S. A. (2002). "The impact of aging on sexual function in women and their partners." Arch Sex Behav 31(5): 431-7. Abstract

Longcope, C., C. Franz, et al. (1986). "Steroid and gonadotropin levels in women during the peri-menopausal years." Maturitas 8(3): 189-96. Abstract

Manonai, J., U. Theppisai, et al. (2001). "The effect of estradiol vaginal tablet and conjugated estrogen cream on urogenital symptoms in postmenopausal women: a comparative study." J Obstet Gynaecol Res 27(5): 255-60. Abstract

Nilsson K, Heimer G. Low-dose oestradiol in the treatment of urogenital oestrogen deficiency--a pharmacokinetic and pharmacodynamic study. Maturitas. 1992 Oct;15(2):121-7. Abstract

Notelovitz M. Urogenital aging: solutions in clinical practice. Int J Gynaecol Obstet. 1997 Oct;59 Suppl 1:S35-9. Review. Abstract

Pritchard KI. The role of hormone replacement therapy in women with a previous diagnosis of breast cancer and a review of possible alternatives. Ann Oncol. 2001 Mar;12(3):301-10. Review. Abstract

Rioux JE, Devlin C, Gelfand MM, Steinberg WM, Hepburn DS. 17beta-estradiol vaginal tablet versus conjugated equine estrogen vaginal cream to relieve menopausal atrophic vaginitis. Menopause. 2000 May-Jun;7(3):156-61. Abstract

Sarrel, P. M. (1987). "Sexuality in the middle years." Obstet Gynecol Clin North Am 14(1): 49-62. Abstract

Sarrel, P. M. (1990). "Sexuality and menopause." Obstet Gynecol 75(4 Suppl): 26S-30S; discussion 31S-35S. Abstract

Sarrel, PM J Women's Health Gend Based Med 2000:9 (suppl 1): S-25-S32

Company Novonordisk pharmaceuticals, marketed by Pharmacia-Pfizer (merged this year) in US http://www.vagifem.com

Everything You Always Wanted to Know About Lubrication...But Were Afraid to Ask, Newsletter #70-March/April 2002. Full Text