Let's Talk About Sex (Hurting), Baby
Nov 30, 2024
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Ok, that's not exactly how the song went. It did say:
Let's talk about all the good things and the bad things, that may be
I don't think we actually did talk about the bad things, though.
Pain is one of them.
This in and of itself is a huge topic with a range of causes and treatments.
We'll discuss here pain due to genitourinary syndrome of menopause (previously called vaginal atrophy). This is the vaginal dryness making it feel like a desert downthere, a prickly cactus-filled dry desert.
With the loss of estrogen in menopause, collagen is compromised which in turn compromises moisture (hyaluronic acid no longer has collagen to support it).
On exam, the menopausal vagina and its entrance (called the introitus) have a characteristic appearance: a narrowed introitus, thin pale skin both outside and inside. The entire architecture of the organ looks different.
Patients may not know this because they a) aren't examining their own vaginas and b) they were never told this could happen.
They find out when they try to have intercourse and no longer can due to lack of lubrication and pain. It all tracks though - there's a narrowed opening for penetration and the skin isn't as moisturized and elastic. Ouch.
So what can we do?
Use it
Moisturize it
Estrogenize it
Continued penetration, whether by a partner or vaginal dilators, with or without help from pelvic floor physical therapy, is recommended.
Vaginal moisture is part of a woman's daily hygiene and moisture routine. This is different from lubricant which is used just prior to intercourse. This is news to most of my patients when we have this conversation.
Vaginal moisturizers purchased over the counter may contain hyaluronic acid (frequently found in face creams which allow the tissue to retain moisture).
Household items that can be used as vaginal moisturizer (just at the opening or outside):
coconut oil
olive oil
Estrogen. Ultimately the loss of estrogen is the root cause of genitourinary syndrome of menopause, so replacing it makes sense.
Vaginal estrogen typically comes as estradiol which is bio-identical to our most potent type of estrogen. Newer formulations are being studied containing estriol, a weaker estrogen.
Vaginal estrogen, with the exception of one ring form (Femring), will not release systemic levels of estrogen. The levels may initially increase but stay within the postmenopausal range. The risks we typically think of with systemic estrogen at older ages (heart attack, stroke, VTE) are not elevated with vaginal application.
This is SUCH a low risk, high reward treatment. Just a banger (pun intended) of a treatment for any woman and prescription writer.
In a patient with a history of breast cancer, there's lacking data about whether vaginal estradiol or estriol (a weaker estrogen) is safe. If it's going to be considered, the decision must involve the patient and her oncologist, of course.
Other treatment options include:
vaginal DHEA
lidocaine applied to the vestibule
vaginal laser
There are multiple treatment options here, actionable items both on the part of the patient and me taking care of her. I can layer treatments to offer the most help and relief to my hurting, distressed patients (even in a breast cancer survivor).
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