Maintaining Sexual Health After Menopause

Vulvovaginal atrophy after menopause can lead to painful intercourse but therapies exist

/ Author:  / Reviewed by: Joseph V. Madia, MD Beth Bolt, RPh

(RxWiki News) A woman's body undergoes a wide range of changes when she begins menopause. Without treatment, some of these changes may influence her quality of life.

One such change that could affect a woman's quality of life is a condition called vulvovaginal atrophy, which can occur in women after menopause.

Vulvovaginal atrophy refers to the thinning of the inner vaginal tissues once a woman's body stops producing as much of the hormone estrogen.

This atrophy can lead to painful intercourse for some women. However, there are several treatments available to address the painful intercourse.

The condition and treatments for it were discussed in a recent medical statement.

"Discuss menopausal changes with your OB/GYN."

A position statement on vulvovaginal atrophy was developed by the North American Menopause Society's 2013 Symptomatic Vulvovaginal Atrophy Advisory Panel, led by Chair Margery L.S. Gass, MD.

According to the statement's background research, approximately 20 to 45 percent of post-menopausal women experience symptoms of vulvovaginal atrophy, though the number is likely higher because of under-reporting.

Further, only a small number of women seek treatment for their symptoms or receive help from their healthcare providers.

"Vulvovaginal atrophy can be progressive [get worse] and less likely to resolve without intervention," the statement notes. "It can have a significant effect on a woman's sexual health and quality of life."

In fact, the statement notes that other research has shown that high percentages of women experiencing vulvovaginal atrophy report quality of life losses, such as lost intimacy with a partner, feeling "old," negative effects on their relationship or marriage, a negative effect on self-esteem and negative effects on sleep and general enjoyment of life.

The statement notes that one option for women is to try over-the-counter creams or gels that may help with lubrication if women experience painful intercourse.

Often, however, these products are not sufficient. The next line of therapy usually includes a product with estrogen.

Estrogen is currently regarded as the most effective treatment for women with moderate to severe symptoms of vulvovaginal atrophy and painful intercourse, also called dyspareunia.

The first option for estrogen treatment is a vaginal topical cream, or else a ring or tablet that provides vaginal estrogen.

This therapy is generally a cream containing estrogen hormone that is applied to the vagina. It functions by returning the vaginal tissue to its less thinned form before the woman's body stopped producing as much estrogen.

The statement recommends that a woman apply the dose of estrogen cream at least 12 hours before intercourse to prevent the estrogen from being absorbed by her partner. Dosages generally are administered two to three times a week.

An additional option is for women to use hormone replacement therapy.

Some women who receive hormone replacement therapy will still experience some vaginal symptoms and may require a vaginal estrogen as well.

Women who have a history of breast cancer will need to discuss their potential use of estrogen with their doctors.

Some women who have had breast cancer and use an estrogen ring or tablet have experienced an increase in estrogen circulating throughout their body. However, it generally fades within a month, the statement notes.

Regardless, there is not good data about the possible effects or safety of local estrogen use in women who have had breast cancer.

The statement notes that women experiencing vulvovaginal atrophy may use vaginal estrogen for as long as they experience painful symptoms.

Currently, there is not research data that looks at the safety of vaginal estrogen for longer than one year, but no time limits have been established.

Some women who use estrogen also require progestogen hormone to prevent an overstimulation of the endometrium.

However, those who use a low dose of vaginal estrogen should not need progestogen if they do not have a uterus (have had a hysterectomy) and usually should not need the additional hormone even if they do still have a uterus.

"If a woman is at high risk of endometrial cancer or is using a higher dose of vaginal ET, transvaginal ultrasound or intermittent progestogen therapy may be considered," the statement notes.

The only type of prescription non-hormonal therapy available to treat the painful intercourse that results from vulvovaginal atrophy is a medication called ospemifeneHowever, ospemifene is still very new and has not been compared in direct trials with vaginal estrogen.

Ospemifene, which goes by the brand name Osphena, also contains a black box warning about risks of blood clots in women.

"Choice of therapy depends on the severity of symptoms, the effectiveness and safety of therapy for the individual patient and patient preference," the statement notes.

Finally, the statement notes that it is important that post-menopausal women be proactively educated about their vaginal health.

The statement was published in the September issue of the journal Menopause.

The statement's creation was funded through donations to the North American Menopause Society. No conflicts of interest were reported.

Review Date: 
September 30, 2013
Last Updated:
January 2, 2014