Vaginal dryness

Vaginal dryness or the medical term atrophic vaginitis, is defined as a lack of adequate moisture in the vaginal area. Vaginal dryness may be a problem for women at any age, although it occurs more frequently in older women, particularly after menopause. Vaginal moisture is mainly produced at the top of the vagina by the cervix. The moisture is slightly acidic in order to fight against infections, such as thrush. When sexually aroused, a woman’s blood vessels receive more blood flow, stimulating the secretion of fluids and increasing vaginal lubrication.

When women have sex, two glands (called Bartholin’s glands) produce extra moisture in order to provide good lubrication during intercourse. However, lack of moisture or vaginal dryness during sex can become a problem.

There can be a number of reasons for vaginal dryness, such as:

• lack of foreplay
• not feeling aroused
• relationship problems
• feelings of guilt or worry
• take contraceptive pills or antidepressants
• have your womb removed (a hysterectomy)
• have cancer treatments, such as chemotherapy
• as a result of breastfeeding, as estrogen levels are low
• use perfumed soaps, washes or douches in and around your vagina
• have an underlying condition, such as diabetes or Sjögren’s syndrome.

Many women find vaginal dryness a problem after menopause as a result of the lack of estrogen in their bodies. As a result of this, the vagina loses elasticity and the lining becomes thinner and dryer. Further irritation can also occur as the vagina becomes less acidic and loses some of the bacteria used to fight against infections.

Vaginal dryness affects many women, although they frequently don’t bring up the topic with their doctors.

If vaginal dryness affects your lifestyle, in particular your sex life and relationship with your partner, consider making an appointment with your doctor. Living with uncomfortable vaginal dryness doesn’t have to be part of getting older.

A dry vagina can be treated fairly easily by using lubrications. Water based lubricants can be used for intercourse. These are available to buy at your local pharmacy or supermarket and you do not need a prescription. Non water based lubricants can damage condoms.

Vaginal dryness causes

Any woman can be affected by vaginal dryness, although it is most common in women who have experienced the menopause. It affects over half of 51-60 year olds. Around a quarter of women aged between 50-59 experience dryness during sex and some women experience pain. If you are in pain, get advice on medicines you can take.

Reduced estrogen levels are the main cause of vaginal dryness. Estrogen, a female hormone, helps keep vaginal tissue healthy by maintaining normal vaginal lubrication, tissue elasticity and acidity. Other causes of vaginal dryness include certain medical conditions or hygiene practices.

Estrogen levels can fall for a number of reasons:

• Breast-feeding
• Childbirth
• Cigarette smoking
• Effects on your ovaries from cancer therapy
• Immune disorders
• Menopause (when persistent vaginal dryness may occur)
• Perimenopause (the transition time before menopause)
• Oophorectomy (ovary removal surgery)
• Use of anti-estrogen medication
• Low levels of estrogen
• Some types of contraception

Other causes of vaginal dryness include:

• Douching
• Use of hygiene products, such as feminine sprays and harsh soaps
• Sjogren’s syndrome
• Use of allergy and cold medications
• Stress
• Washing powders
• Swimming pool and hot tub chemicals
• Not enough foreplay or arousal
• Cancer treatment.

Certain medicines, such as allergy treatments or antidepressants, can also dry the vagina and vaginal tissues.

When menopause strikes, hormonal changes that occur in the body can disrupt this process, both during sex and in daily life. Reduced estrogen levels can cause the vulva and vaginal tissues to become thinner, and what was once an acidic environment can quickly become more alkaline, increasing irritation and the likelihood of vaginal infections.

Pre-menopausal women who have had their ovaries removed during a hysterectomy may also have a dry vagina as a result of a loss of hormones. People who have had chemotherapy may also experience this.

Vaginal dryness symptoms

Symptoms of vaginal dryness can range in severity, from mild and irritating to significantly life hindering.

Common symptoms of vaginal dryness can include:

• Itching in and around your vagina,
• Light bleeding during sex,
• Painful intercourse,
• Stinging,
• Irritation,
• General discomfort,
• Urinary frequency (need to urinate more often than usual),
• Keep getting urinary tract infections (UTIs),
• Burning,
• Discomfort when wearing pants, and
• Pressure.

These symptoms may make you feel less like you want to have sex.

Fortunately, there are many steps you can take towards managing vaginal dryness, and there are varying degrees of treatment options available, both hormonal and nonhormonal.

Vaginal dryness treatment

When it comes to treating any symptom of menopause, it’s recommended that you start with the least invasive methods first.

Home remedies for vaginal dryness

You can try these things before you see a doctor. You can get most of them from a pharmacy without a prescription. Examples of commonly used lubricants, moisturizers, and vaginal estrogen products:

• Water-based lubricants: Astroglide, FemGlide, Just Like Me, K-Y Jelly, Pre-Seed, Slippery Stuff, Summer’s Eve, others
• Silicone-based lubricants: ID Millennium, Pink, Pjur, Pure Pleasure, others
• Vaginal moisturizers: Fresh Start, K-Y Silk-E, Moist Again, Replens, K-Y Liquibeads, others
• Vaginal estrogen products: Vagifem (vaginal tablet), Estrace (cream), Neo-Estrone (cream), Premarin (cream), Estring (low-dose vaginal ring)

Lubricants and moisturizers are effective in relieving pain during intercourse for many midlife women with mild to moderate vaginal dryness, so these products are a natural place to start. That’s particularly the case for women who are not candidates for vaginal estrogen therapy or are not comfortable using it.

If you have more severe vaginal dryness and related pain, or if lubricants and moisturizers don’t work well for you, see your healthcare provider. There may be a more serious cause of your discomfort that should be diagnosed and treated. You and your healthcare provider can also discuss low-dose vaginal estrogen products. These prescription-only products deliver estrogen directly to the vagina, with minimal absorption to the rest of the body, and restore vaginal tissue thickness and flexibility. These actions may help prevent other sexual problems (such as worsening pain during sex, vaginismus, or diminished arousal or orgasm) that can result from chronically painful sex.

Lubricants

Vaginal lubricants work by reducing the friction associated with thin, dry genital tissue. They come in liquid or gel form and are applied to the vagina and vulva (and, if desired, to a partner’s penis) right before sex. Lubricants are not absorbed into the skin, are immediate-acting, and provide temporary relief from vaginal dryness and related pain during sex. They are particularly appropriate for midlife women whose vaginal dryness is an issue only or primarily during sex.

A wide variety of lubricants are commercially available, either as water-based, silicone-based, or oil-based products. Water-based lubricants have the advantage of being nonstaining. Oil-based lubricants (such as petroleum jelly and baby oil) should be avoided, as they can cause vaginal irritation and are associated with high rates of latex condom breakage that can lead to sexually transmitted infections. Polyurethane condoms do not break with oil-based lubricants.

Moisturizers

Like lubricants, vaginal moisturizers reduce the painful friction that sex can cause as a result of vaginal atrophy. Additionally, moisturizers, unlike lubricants, are absorbed into the skin and cling to the vaginal lining in a way that mimics natural secretions. Another difference is that moisturizers are applied regularly, not just before sex, and their effects are more long-term, lasting up to 3 or 4 days. Some moisturizers have an applicator to help place the product into the vagina.

Because moisturizers maintain vaginal moisture and acidity, they are particularly appropriate for midlife women who are bothered by symptoms of vaginal dryness (such as irritation and burning) that are not limited to sexual activity. Some women who regularly use moisturizers still use a lubricant as needed before sex, for additional lubrication and comfort. For both moisturizers and lubricants, you may need to experiment with several products to find the one that’s best for you.

Natural oils

Natural oils, such as vitamin E, grapeseed, sweet almond oil, or coconut oil, gently soothe the vaginal walls when applied topically. Natural oils can be applied following a bath or sexual intercourse, and can help to restore natural balance and rehydrate the vaginal walls.

More fluids

For a well-hydrated vagina, try drinking at least ten glasses of water each day, and top up with juices; specifically pineapple, lemon, and orange juice. These fruit saps contain a lot of enzymes, as well as vitamin C, to reduce subtle infections promoting poor vaginal discharge.

Avoiding harsh soap

If you are experiencing even mild irritation or discomfort, the first thing you should do is stop using soap on the inner parts of your vulva – clean water is perfectly adequate for washing down there. Also, only use unscented toilet paper, wash your underwear in detergents free of dyes or perfumes, and stop using fabric softeners, bubble bath, and products that use petroleum jelly or mineral oil. This will help to restore the natural pH balance in the vaginal region.

Low-dose vaginal estrogen therapy

Estrogen products designed for vaginal application have been proven to restore vaginal blood flow and improve the thickness and stretchiness of vaginal tissue in peri- and postmenopausal women. These products act to reverse the thinning and dryness of vaginal tissues rather than just providing the temporary relief that lubricants and moisturizers do. For this reason, low-dose vaginal estrogen is appropriate in most cases for peri- and postmenopausal women who do not get sufficient relief from moisturizers or lubricants or whose symptoms of vaginal atrophy are interfering with their quality of life.

Women who need relief from other significant symptoms of menopause, such as hot flashes and night sweats, may want to consider higher-dose hormone therapy that raises estrogen levels throughout the body. However, for women without those other menopause symptoms, vaginal estrogen should be used since it is concentrated where it is needed and minimizes blood levels and possible side effects of estrogen on the rest of the body. Additionally, severe vaginal atrophy may respond more quickly to vaginal estrogen therapy than to hormone pills or patches that deliver estrogen throughout the body.

Vaginal estrogen should be used at the lowest effective dose, again to limit any effects elsewhere in the body. If you’ve had breast cancer, be sure to mention this to your healthcare provider before using estrogen in any form so that you can properly weigh its benefits and risks.

Low-dose vaginal estrogen is very effective against atrophy-related pain during sex, with up to 93% of women reporting significant improvement and 57% to 75% reporting that their sexual comfort is restored ¹, ². Improvements in vaginal moisture and health typically occur within a few weeks of starting therapy, although relief from severe vaginal atrophy can take several months.

Vaginal estrogen is available in several forms, all of which require a prescription:

• Vaginal creams are applied in small amounts (0.5-1.0 g) in the vagina 2 to 3 times a week. These products, known by the brand names Premarin, Estrace, and (in Canada) Neo-Estrone, should not be used as a lubricant before intercourse since the estrogen can be absorbed through a partner’s skin.
• The low-dose vaginal ring, Estring, is inserted into the vagina and worn for 3 months before being taken out and replaced; it does not need to be removed before sex. This low-dose estrogen ring is designed only to treat vaginal dryness and should not be confused with Femring, which is another vaginal ring that releases higher doses of estrogen for treating hot flashes and other symptoms of menopause.
• The vaginal tablet, Vagifem, is placed in the vagina twice a week using an applicator (recommended) or a finger. Many women find the estrogen tablet less messy than estrogen creams.

All forms of vaginal estrogen are similarly effective, and most forms are associated with minimal side effects, although women’s individual responses may differ. The form chosen should be based on your individual preference, factoring in cost and insurance coverage, after discussion with your healthcare provider.

If low-dose vaginal estrogen therapy is right for you, you may also use lubricants and moisturizers as needed. Sometimes, after estrogen therapy has restored the vaginal tissues to a more healthy state, it can be stopped and nonhormonal lubricants or moisturizers can be used alone. To maintain the benefit, however, it is important to continue regular vaginal sexual activity.

Systemic hormone therapy

Estrogen products that raise levels of the hormone throughout the body (systemically), not just in the vagina, may be appropriate therapy for vaginal atrophy and related pain during sex in postmenopausal women who also suffer from other distress-causing symptoms of menopause, such as hot flashes and night sweats.

Systemic estrogen products might also be an option in postmenopausal women who don’t get adequate relief from distressing vaginal atrophy with various forms of low-dose vaginal estrogen. In these women, systemic estrogen may be used for a short period to build up vaginal tissue before trying to transition back to a lower-dose vaginal product for longer-term therapy. Systemic estrogen products deliver higher doses of estrogen than low-dose vaginal estrogen products.

These systemic estrogen products are referred to as “hormone therapy” and contain either estrogen alone or estrogen plus progestogen. Estrogen alone is used only for postmenopausal women who have had a hysterectomy (surgery to remove the uterus) because taking estrogen by itself raises the risk of uterine cancer. Adding progestogen (a version of the hormone progesterone) protects against the risk of uterine cancer, so estrogen plus progestogen therapy is used for postmenopausal women who still have their uterus.

Systemic hormone therapy can be taken in various forms:

• As pills
• Via the skin (in patches, gels, creams, or sprays)
• Via the Femring vaginal ring that delivers estrogen at a higher dose than other vaginal estrogen products

Risks and benefits must be weighed

Because systemic hormone therapy has been associated with increased risks of heart attack, stroke, blood clots, and breast cancer, especially in older women and with longer duration of use, healthcare providers generally prescribe the lowest possible dose for the shortest possible time to relieve symptoms of menopause. Whether systemic hormone therapy is right for you depends on your medical history, how comfortable you are with its risks, and how severe your menopausal symptoms are. It’s a decision that you must make in close consultation with your healthcare provider.

Effect on libido uncertain

Although systemic hormone therapy improves vaginal health and may improve sexual function by restoring lubrication and reducing pain during sex, a beneficial effect on libido has not been documented.

Good sex tips

If you want to make the most of your sex life, these sex tips are a good way to start.

Talking and listening to each other about your feelings, preferences and desires can bring you closer together and make sex more enjoyable.

But even the most contented lovers can have fun trying new things. Here are a few ideas.

1. Build anticipation

Agree on a period of time – say one week, or whatever works for you – when you won’t have orgasms or penetrative sex. At first, allow only kissing and holding each other. Gradually move on to touching and stroking each other, masturbation, oral sex, or whatever feels right for you. Avoid orgasm.

At the end of the agreed waiting period, allow yourselves the pleasure of orgasm through any kind of sex you like. This week may help heighten your senses to all the other wonderful feelings you can share when you’re making love.

2. Massage

Massage can help you have very sensual sex. As part of foreplay, it’s a great way to start things off slowly and relax into the feel of each other’s skin as your arousal intensifies.

But a simple massage that doesn’t lead to sex can also work wonders for your sex life. A non-sexual massage will familiarize (or refamiliarize) you with your partner’s body, reduce stress, and reaffirm the intimacy between you.

If you don’t want a massage to lead to sex, discuss this with your partner so you can avoid any misunderstanding.

3. The senses

Good sex can embrace all the senses, not just touch. Scented oil for a massage, music and candles for soft lighting can all be erotic, as well as listening to your partner’s breathing and the sounds they make. But remember not to get oil on a latex condom, as this can damage it.

Taste each other as you kiss. If you both want to, you could mix food and sex – feed each other something delicious and juicy, such as strawberries.

4. Whisper

Whether it’s sweet nothings or your sexy intentions, whispering things to each other can add an extra thrill. It doesn’t have to be during foreplay or sex. Foreplay can start during the day with a sexy phone call or text – this could leave both of you looking forward to the event for hours or days.

This works with texts and emails, too – but make sure you send them to the right person, and remember that your employer has the right to access your work email.

5. Masturbation

Masturbation, by yourself or with your partner, can be a bonus for your sex life. Exploring your own body and sexual responses means you can share this knowledge with your partner.

Masturbating your partner can help you learn more about what turns them on. It can also be an option if one of you doesn’t feel like full sex. Talk about this with your partner.

6. Sex toys

If you and your partner both feel comfortable, using sex toys can be an arousing thing to do together. Some people use vibrators (and more) as an enjoyable part of their sex life. If you’ve never thought about using sex toys before, how do you feel about trying them?

You can buy them online or in sex shops. You don’t have to spend a fortune on toys – you can get creative. Soft hair brushes can feel great against the skin, and making your own games up can be fun.

7. Read a book

There are many books that have exercises and ideas to help you achieve a fulfilling sex life, whatever your age, gender, sexual orientation or taste.

If you’ve never thought about buying a book about sex, why not do it now? You might wish you’d done it years ago.

8. Share fantasies and desires

Everyone has unique fantasies, tastes and preferences when it comes to sex. From earlobes to ankles, hairline to hips, pirates to picnics, don’t be afraid to talk about them.

If you and your partner know about each other’s turn-ons, you can make the most of them.

9. Keep it clean

We’re talking about your general hygiene. You don’t have to keep yourself super-scrubbed: a certain amount of sweat is fine, as long as it isn’t overwhelming.

But be respectful towards your partner, and wash every day to prevent nasty smells and tastes.

10. Relax

Sex with a loving partner can be one of the most beautiful and intense experiences in life.

Sometimes the best sex happens when you’re not worrying about making it exciting or orgasmic. Relax with your partner and great sex may find you.

Breathing exercise for stress

This calming breathing technique for stress, anxiety and panic takes just a few minutes and can be done anywhere.

You will get the most benefit if you do it regularly, as part of your daily routine.

You can do it standing up, sitting in a chair that supports your back, or lying on a bed or yoga mat on the floor.

Make yourself as comfortable as you can. If you can, loosen any clothes that restrict your breathing.

If you’re lying down, place your arms a little bit away from your sides, with the palms up. Let your legs be straight, or bend your knees so your feet are flat on the floor.

If you’re sitting, place your arms on the chair arms.

If you’re sitting or standing, place both feet flat on the ground. Whatever position you’re in, place your feet roughly hip-width apart.

• Let your breath flow as deep down into your belly as is comfortable, without forcing it.
• Try breathing in through your nose and out through your mouth.
• Breathe in gently and regularly. Some people find it helpful to count steadily from 1 to 5. You may not be able to reach 5 at first.
• Then, without pausing or holding your breath, let it flow out gently, counting from 1 to 5 again, if you find this helpful.
• Keep doing this for 3 to 5 minutes.

1. Lose G, Englev E. Oestradiol-releasing vaginal ring versus oestriol vaginal pessaries in the treatment of bothersome lower urinary tract symptoms. Br J Obstet Gynaecol2000;107:1029-1034
2. Simunic V, Banovic I, Ciglar S, et al. Local estrogen treatment in patients with urogenital symptoms. Int J Gynaecol Obstet 2003;82:187-197.