So, what is the problem?
Yes, that area of our bodies is very sensitive to estrogen levels, and after menopause, we simply may not have enough estrogen there to keep those tissues healthy. This happens with natural menopause and it happens with surgical menopause. It even happens when we are taking hrts.
If you did a double-take at that last sentence, you've got lots of company. But in fact current prescribing guidelines for estrogen hrts call for using the lowest dose that meets one's objectives in taking hrt. That's for a good reason: our breast cancer risk seems to correlate fairly well to our lifetime exposure to estrogen, so the least estrogen that works for our needs, the lower our overall risk.
But while that may work out fine for systemic (whole body) needs, it may not cover the very specific needs of these particular tissues. Wouldn't the answer then be to simply take a larger hrt dose so that it would? No, because then that risk goes back up.
Today's typical hrt strategy is to meet our greater vaginal estrogen needs in a different way, one that doesn't do as much to raise overall risks but does serve to keep those critical tissues healthy. That strategy is to use as low a systemic hrt dose as otherwise meets our needs and to supplement that with a second form of estrogen hrt that specifically meets vaginal needs. That means a little more work to manage our hrt and, yes, a little more expense, but the benefit of those costs is meeting all our needs at a lower level of health risk.
Vaginal atrophy: what it does
Estrogen supports a number of functions in vaginal and urinary tissues. It helps maintain elasticity, moisture, lubrication, immune function, and sensation. Without estrogen, blood vessels shrivel up and become less functional, and our nerves in that area begin to deteriorate. We can't bring blood to initiate the healing processes that protect us from infection. At the same time, these more delicate tissues are even more susceptible to injury or irritation.
That means that without estrogen, vaginal (and to some extent, vulval) tissues become dry all of the time, and hence more irritated by things like soaps or even contact with underwear. It means that we may be more susceptible to infections and it means that we may be more allergic or at least more prone to irritations, rashes, or itching due to contact with products like soaps, fragrances, or laundry products, even ones that we weren't bothered by in the past.
The loss of sensation, caused by the nerves being starved, means that while we may feel irritation just fine, we tend not to feel the pleasurable sensations of arousal or orgasm. "Dead down there" is a common way of expressing this. Because we don't have the capability to respond to arousal with tissue swelling and lubrication, we literally don't feel aroused. And the lack of elasticity and lubrication means that even if we go ahead with penetration, it will be at best uncomfortable and unpleasing, and at worst cause tearing and further irritation. No matter whether or not we provide a systemic "itch" for sexual contact with testosterone, if we can't respond physically because of the effects of low estrogen in these tissues, we will not seek or enjoy sexual relations. We'll talk more about the issue of libido support in another post here, but this is the important relationship: if the equipment isn't working, it doesn't matter how hard you push it. And estrogen is the foundation of "working" here.
So what do we do?
HRTs intended specifically to meet vaginal estrogen needs are different from those for systemic needs. It's especially important not to confuse them with products for systemic use that are also delivered through vaginal tissues. Our estrogens HRTs page distinguishes these, so check out your brands there to make sure you've got the correct one for your intentions: even health practitioners have been known to mix this up.
Vaginal estrogen HRTs are all designed to be delivered in vehicles that are non-irritating to atrophied vaginal tissues and well-absorbed by them. Even more importantly, they deliver only a very low dose of estrogen, only enough to meet the local tissue needs. The objective of this is to have all of the dose absorbed and used in those local tissues rather than being passed along to systemic circulation. And that means that adding a vaginal estrogen supplement doesn't mean making an adjustment to our systemic HRT to take that addition into account.
It also means—and this is important—that we can use it intermittently. Our systemic HRT, you'll remember from discussions elsewhere on this site, needs to be kept at a fairly consistent level to avoid causing symptoms from fluctuating hormone levels. But because vaginal HRTs don't affect systemic levels, they can be used only as often as needed to provide the level of maintenance coverage we turn out to need.
Most vaginal HRTs are given at a relatively frequent dose interval, usually daily, for a six- to eight-week period. This provides a steady supply of estrogen to promote recovery of health.
Often, we use a cream for this treatment phase: it spreads out well and provides maximal contact with tissues. Further, these are older products and doctors are more familiar and comfortable with them, hence more likely to prescribe them.
Other options are available, however: typically these are rings and vaginal tablets, either retail prescription or compounded. While they may be less messy than creams, because they are low doses meant for maintenance, this first, treatment phase can take longer with these forms. Whether or not this is a good idea for any particular individual really depends upon just how uncomfortable they are and how rapidly they want to turn things around.
It's perfectly legitimate to use a combined approach: a cream for the treatment phase and then a switch to another form for long term maintenance. Alternatively, one can continue using a cream and simply use a smaller amount of it at a less frequent interval, making it less messy and inconvenient. All of the commercial vaginal estrogen HRTs work, so it's really a matter of preference.
What we can expect from vaginal estrogen supplementation
It's not at all uncommon to see reports of vaginal infections in the early weeks of treatment. These are due to the impaired immune function recovering at a different pace from other aspects of tissue healing, such that the vagina becomes a fertile place for bacterial growth before we're really able to fight those bacteria off. Additionally, using the cream runs the risk of introducing infections through the applicator and tube if we are not careful with their cleanliness.
Infection is not a contraindication for continued HRT use, however, and infections can (and should) be treated at the same time. It may take more than one round of treatment before health is restored and we require less intervention, so some persistence can be needed to see this process through. What's important to keep in mind, though, is that it's not the new vaginal HRT causing the infections (this is a common misunderstanding), but rather, it's the stage of healing that actually makes us susceptible to the infections.
Now, we've said above that the idea of the low dose level of these products is so that they will be consumed entirely locally, without systemic impact. And that's true. Except, maybe not so much at first. When we first begin treating established vaginal atrophy, those tissues may have lost enough of their circulatory capacity that they can't pick up and distribute all of the estrogen quickly enough and some of it does "leak" into systemic use. We may experience a few hot flashes from the fluctuation in our systemic levels, or see a slight shift in our usual state of balance.
But because even atrophied tissues can benefit from the estrogen they absorb, healing is happening. And as those tissues recover, they'll use more and more of the dose until that state of total local use is achieved. For this reason, it's generally not considered to be a situation in which we should modify our systemic HRT intake. It's temporary and so long as we're not miserably uncomfortable, we don't need to change anything; we can wait it out, knowing it's time-limited and will gradually be resolving.
So we use the HRT daily for those six to eight weeks and find that things are feeling considerably better. Normal lubrication should be restored and sensation should also be more normal, assuming we experienced no actual nerve damage from our surgeries. Now it's time for maintenance mode.
Our doctors will tell us to use our maintenance vaginal HRT on a less frequent schedule and may suggest once or twice a week. But that's only a rough guess, and we each have to consider tuning that to create our own best schedule.
If we're still using cream, we can also work on determining a reduced dose. What we hear most often is something like "a pea-sized dab a couple times a week," which is pretty vague but is an okay general guess to work from.
For those using a ring, of course, the dose is taken care of (although it's important not to neglect change dates).
For tablet users, the frequency is the only factor to be adjusted, but once to twice a week still seems to be where most users start. If symptoms of dryness or other hallmarks of atrophy return, it should be obvious that the dose or frequency or both should be stepped up a bit. If twice a week is seeming good, it might be reasonable to step down a bit to twice every week and a half, just to make sure that we're not using more than we need. In other words: we feel our way along, looking for our personal bottom limit and then aiming just above that.
The fine print
Great, so what are the drawbacks? Yeah, it's never a free lunch with menopause, so you knew there would likely be a catch or two.
In this case, vaginal atrophy treatment has to lead into vaginal health maintenance, which means that we will need it more or less the rest of our lives—or, at least, until our hormone needs drop so low as to no longer require supplementation. Maintenance requires a lower dose, generally accomplished by a longer dose interval and/or a change of product after initial healing takes place. If we stop using our vaginal estrogen supplement, our atrophy will return: this is an ongoing need, not a "disease" that we will "cure" with a one-time treatment. Just as we have to eat every day to keep nourishing our bodies, so we have to keep providing the estrogen needed to nourish vaginal health.
Vaginal estrogen supplementation isn't for everyone. Those of us who have hormone-sensitive risks in the pelvic area, such as endometriosis, are generally discouraged from using vaginal hrts because they concentrate potentially higher levels of hormones in pelvic circulation.
Those at high risk for estrogen-stimulated cancers anywhere in their bodies who are being treated by estrogen exposure restriction, either by withholding estrogen supplementation or by drugs that specifically combat estrogen exposure, used to be routinely advised not to use vaginal estrogens. Although these products nominally are fully consumed by local tissues and don't spill over into systemic circulation and hence risk, enough has been shown to escape to raise the fear that this might be just enough to help a tumor cell survive. In fact, the North American Menopause Society, in their 2017 position statement on hrt (that was cosigned worldwide) said:
Because of the potential risk of small increases in circulating estrogens, the decision to use low-dose vaginal ET [estrogen therapy] in women with breast cancer should be made in conjunction with their oncologists. This is particularly important for women on aromatase inhibitors (AIs) with suppressed plasma levels of estradiol, although no increased risk was seen in an observational trial of survivors of breast cancer on tamoxifen or AI therapy with low-dose vaginal ET during 3.5 years’ mean follow-up.One other concern we've heard voiced is about transferring hormones to our partners. Yes, this can happen if a cream dose is still present at adequate hormone levels. Timing of use can help manage this. The ring for this use releases such a low level of output that it's certified as safe enough to leave in during intercourse (although you may, of course, remove it if either partner prefers). Otherwise yes, some care is needed but so long as the HRT isn't freshly applied and still present in volume, it's believed that the risk is minimal. For 100% protection, however, a condom can be used as a barrier.
But isn't there some natural solution?
But perhaps what you mean is you prefer something you can purchase over the counter, something made from a blend of herbs, something that doesn't carry the risk of hormones. In that case, we're sorry to have to tell you that this doesn't exist. There is no substance, whether grown in a plant or refined in a lab that can fulfill vaginal estrogen needs other than real human-type estrogen. Yes, there are many sales websites that will try to tell you differently, but in fact these products do not address the specific need for estrogen and so will not treat vaginal atrophy.
Lubricants or vaginal moisturizers may feel soothing, but will not actually promote healing or improve the other physical damages of vaginal atrophy. Some things of this type that users have found useful include commercial moisturizers, commercial lubricants, vitamin E capsules, or small balls of (chilled to harden) coconut oil. These can be good things to try if your other options are limited or you believe that dryness is the only symptom you're experiencing, but they aren't really treatments for vaginal atrophy.
Douching, especially with perfumed products, is not recommended in vaginal atrophy because douche solutions can actually damage tissues further and increase infection risk. Similarly, while douching with live-culture yogurt or other probiotic agents may help restore a good flora balance after health is restored, they will not alone restore that health and will not do so durably.
Must it be treated? Of course not. It's up to us to choose what we consider important. Some have said they feel the loss of sexual responsiveness grants them a return to a purer, more childlike condition. Others don't find the symptoms troubling or find that simple over the counter lubricants and a switch to unscented washing products are adequate to deal with the degree of atrophy that develops.
Each of us gets to decide these things for themself. What we want you to know, however, is that this is a treatable condition, not a life sentence. Menopause does not mean "dead down there" or intractable pain. If you aren't happy with the state of your vaginal health, it needs to start by speaking up. Yes, we know it's hard if you're not used to discussing this part of your body or your sexual needs. You may be embarrassed, or you may worry that your doctor may make you feel wanton or unclean. But this is perfectly normal physiology and your doctor really should be a mature enough individual to handle such a request politely and smoothly. In fact, shame on them for not asking directly whether you need treatment of this kind in the first place. At some point, though, one or the other of you needs to suck it up and just raise the question, and since you're the one who's hurting, yes, we're looking at you.
Not sure what to say? How about something along the lines of "Doctor, I'm concerned about developing vaginal atrophy. Lately I've been experiencing dryness and loss of sensation, and I'd like to consider using some supplemental vaginal estrogen to help keep things healthy. Would you write me a prescription for this?"
More questions?
Beyond this, we're always happy to discuss specifics on our forums, so feel free to join us there.
*Update: A new name for this has been proposed for this condition, GSM or "Genitourinary Syndrome of Menopause." This doesn't represent a change in thinking about treatment, but it is hoped that it will make it easier to discuss. You can read more about this proposed change in terminology in a separate entry.
