What Can I Do About Painful Sex After Menopause?
Menopause is a challenging time for many reasons, as we are forced to face the reality of our own aging and loss of fertility, as well as a myriad of unpleasant symptoms that come from a drop in our ovarian hormone production. While the average age for ovarian function to cease is 51, in many women it can occur much earlier, or even as late as 60.
Right at the same time as we are dealing with the emotional realties of menopause, seeing new wrinkles in the mirror and a new tire forming around our waist, we often are thrown another loop which is that sex can become painful. Dropping estrogen levels cause very real changes in the vagina including a lack of moisture production and a thinning of the tissue which also becomes less elastic and prone to tear. The vaginal tissue becomes pale as blood flow to the areas is decreased, and the vagina can start to shrink to a point at which intercourse can be difficult or even impossible.
Fibroids occur in 40% of women and are usually asymptomatic, but they can also cause health issues including heavy bleeding and pain. Very rarely heavy menstrual bleeding is a sign of uterine cancer, but cancer is less likely to be cyclic (monthly) and is very uncommon in pre-menopausal women.
Luckily there are very good treatments for post-menopausal vaginal changes and this pain and dryness can almost always be resolved. Since the problem is caused by low estrogen, the mainstay of treatment is putting estrogen back into the tissue. For women experiencing a wide range of menopausal symptoms such as hot flashes, and night sweats as well as vaginal pain, taking an estrogen product that treats the whole body may be appropriate. For women with isolated vaginal pain and dryness, estrogen can be directly applied to the vagina at a much lower dose and this avoids some of the side effects (such as the potential for increasing breast cancer risk) that the systemic (total body) products may have. Even if a systemic product is used, additional vaginally administered estrogen can help in many cases.
There are several estrogen products on the market that we recommend to treat vaginal pain and dryness and each has pros and cons. They all contain the same product, which is bio-identical estradiol (biologically the same as human estrogen). The first is a cream which is applied with an inserter 2-3 times weekly (”Estrace”). It works well but is a bit messy and hard to keep up with. The second is a tablet which is also inserted with an applicator (“Vagifem”). It is less messy but also is hard to keep up with. The third is a circular flexible ring which is placed and removed by the patient and stays in the vagina for 3 months (“Estring”). Many of our patients prefer this as it is no trouble to keep up with and delivers a small even dose every day, and overall is the lowest dose product which has the best results. Interestingly studies on Estring show that such a minuscule amount of estrogen gets above the waist (it is almost all bound locally) that even breast cancer patients can usually safely use it once they are cancer free. None of these work overnight as they require time for new healthy tissue to replace the old unhealthy tissue, and results may take 3-6 months to be noticeable. In the meantime using a lubricant such as Astroglide can help to reduce pain.
A unique non-estrogen product is also available in pill form to treat post-menopausal vaginal pain and dryness. “Osphena” is a not estrogen but is in a class of drugs called “SERMs” (selective estrogen receptor modulators) which act like estrogen in some tissues but like anti-estrogens in others. Other very similar drugs include Tamoxifen which is used to reduce breast cancer risk but also helps bone density, and Raloxifene which is a bone builder but also reduces breast cancer risk. Osphena was initially being developed as a bone builder and it does have a good effect on the bone, but incidentally was found to have an estrogen-like effect in the vagina, so the decision was made to market it for that purpose. While it has not been studied enough on the breast yet to make this promise, it is certainly likely to decrease breast cancer risk since the other drugs in this class do.
One benefit is that it is a daily pill and some patients find that preferable to placing something in the vagina. Unfortunately the main side effect is hot flashes. Since Osphena is an anti-estrogen in some areas of the body, one of those areas is unfortunately the temperature sensors in our brain. For this reason we rarely recommend Osphena to a woman early in menopause who is already experiencing hot flashes, and also cannot give it to patients who are taking systemic estrogen for hot flashes (you should not take both estrogen and an anti-estrogen simultaneously). A good candidate for Osphena might be a woman in her 60s with vaginal pain and dryness who is past the point of hot flashes and prefers a pill to a vaginal medication.
Vaginal treatments using heat to intentionally damage the tissue and cause collagen to reform and build can also be helpful. Thermiva uses radiofrequency to heat the vaginal tissue over a 20 minute cycle with minimal pain in the office, and after three monthly treatments we have seen great results with improving vaginal moisture as well as sensation.
Of course there are some non-hormonal reasons for vaginal pain after menopause and a physical exam with your provider is important to make sure there is not something more serious going on. While it is our job to ask, don’t be afraid to bring up this very intimate topic with your provider at your next visit.