Vaginal Dryness

Why Is My Vagina Dry?

Many women suffer from vaginal dryness in various stages of life.   Although there are several causes of vaginal dryness, hormonal changes are one of the biggest reasons.   This condition can be extremely uncomfortable and more importantly can interfere with maintaining intimacy in your relationships.   Here we will discuss the causes and best treatment options available.

Vaginal Dryness

Five Common Causes Of Vaginal Dryness:

1. Estrogen deficiency — Low estrogen levels can reduce the natural elasticity and lubrication of the vaginal tissue. The walls of the vagina can become thin and fragile, making them less resistant to injury and “trauma.” This loss of estrogen is common during peri-menopause, menopause, after childbirth, and during breast feeding. Cancer treatments such as radiation and chemotherapy or surgery that includes removal of the ovaries can lead to an abrupt loss of estrogen. Another common lifestyle cause of vaginal dryness is smoking, which can cause earlier menopause and low estrogen levels.

2. Medication side effects — Many medications can cause vaginal dryness.

• Birth Control Pills » can cause an increase in Sex Hormone Binding Globulin (SHBG), a carrier protein made by the liver that binds up excess estrogen and testosterone. This can cause symptoms of vaginal dryness, painful sex and a drop in libido.
• Anti-histamines » found in allergy and cold medications can also have a drying effect on inner lining tissue (mouth, nose, vagina) and can decrease natural lubrication.
• Certain medications » for high blood pressure, like diuretics and anti-ulcer drugs can have a drying effect.
• Tamoxifen and Evista » are estrogen receptor blockers. These medications can cause vaginal dryness by blocking estrogen receptors in the vaginal tissue. Arimidex prevents the conversion of testosterone to estrogen throughout the body and can affect the vagina in particular.
• Chemotherapy » medications can also cause dryness by shutting down the release of estrogen from the ovaries.

3. Emotional or Psychological Issues

• Lack of arousal, insufficient arousal or sexual problems with a partner (such as impotence) can reduce natural lubrication related to a blunted sexual response.
• Anxiety and stress can interfere with sexual desire. Addressing underlying tension or worry may be the key to improving dryness symptoms. “Men have sex to relax, women need to be relaxed to have sex,” says Phil Altman, owner of HealthyChoice Pharmacy, who specializes in compounding bio-identical hormones and non-hormonal vaginal moisturizers.

4. Vaginal Irritants

• The vaginal tissues are easily irritated by chemicals and additives in soaps, perfumes, hygiene products, lubricants, laundry detergents and gels. Even dyes on clothing and underwear could result in an allergic reaction.
• Beware of reactions to tampons and latex condoms.

5. Other skin conditions

Sometimes vaginal dryness or vulvar discomfort may be related to the presence of other skin conditions such as:

• Generalized dermatitis – another term for skin inflammation from general irritation, allergic reactions or chafing.
• Lichen sclerosis – a chronic inflammatory skin condition that can create thickened, itchy skin that easily cracks or fissures.
• Precancerous growths on the outer labia and vaginal tissue.
• Fissuring or “cuts” on the skin related to infections like yeast or herpes.

It is important to have your doctor or health care provider carefully inspect the area to check for all causes of dryness.

Vaginal Dryness Treatment Options

What are some vaginal dryness treatment options?

Once you have been evaluated by your gynecologist or health care practitioner to rule out infections and other skin conditions that can cause dryness, there are different treatment options available to help with symptoms.   Bear in mind, that knowing WHY you have vaginal dryness will determine which treatments will work best for you.

1. Lubricants during sex — Most women have already tried a variety of lubricants to make sex more comfortable. This may give some temporary relief from dryness and painful sex, but it does not address the underlying problem if dryness is related to estrogen-deficiency.   There are many over the counter options available but be aware that many lubricants tend to contain harmful chemicals that are absorbed through the vaginal tissue and can interrupt the normal acid-base balance of the vagina.   Additionally, many chemicals found in lubricants can upset the normal pH balance and harm the beneficial bacteria in the vagina that works to protect you from infection.

What to consider before using a lubricant:
➔ Look for a product with the healthiest and fewest ingredients possible. This will hopefully reduce the chances of having an allergic reaction to the product.
➔ Avoid using lubricants with warming or numbing qualities. This will make the area less sensitive to pain and will prevent you from finding out if you are causing any physical harm or injury.
➔ Avoid products that contain glycerin, which can upset the normal bacterial balance and lead to infection
➔ Avoid propylene glycol, the ingredient found in anti-freeze. Certainly not something you want to put in your body.
What to use:
» Aloe Cadabra — 95% aloe, organic, with vitamin E, sodium benzoate, potassium sorbate (both preservatives recognized by FDA as safe) and organic vanilla concentrate.
» Sliquid H20 — This vegan-friendly water-based lubricant is free of parabens (not friendly to the breast) contains cyamopsis, purified plant water, cellulose, potassium sorbate and citric acid. According to Amazon reviewers, “no smell, no taste…no funky odors afterwards.”
» Wet Platinum Premium Lubricant — A silicone-based lubricant with minimal chemical additives. Aside from the bottle being poorly designed (leaks easily), the product itself works well and lasts. Be aware that silicone-based lubricants will stain sheets.
» Organic Glide — A very popular oil-based lubricant made with olus oil, olive fruit oil, argania kernel oil and resveratrol ferment extract. Very popular with my patients because it lasts a long time and works well. Careful with condom use as the oil may disrupt the integrity of the condom.
» Check your pantry — olive oil and coconut oil are often great go-to’s that are natural and work well. Oils can be a little messy but can be effective and are less likely to cause an irritating reaction.

2. Vaginal Moisturizers — There are many over-the counter vaginal moisturizers that work to reduce dryness by hydrating the vaginal tissue. A single application can last for a few days. Think of it as moisturizing your skin – something you would normally do on a daily basis (on a good week). This will not replace the need for a lubricant during sex, but it may relieve some of the symptoms you experience not related to sex.

What to consider before using vaginal moisturizers:
➔ See the “what to consider before using…” section under Vaginal Lubricants. You should be cautious about the chemicals that are included in any over-the-counter formulas.
➔ Replens and Luvena are popular options that will give you short term relief of symptoms, but they do not reverse the ongoing changes related to estrogen loss.
➔ The ingredient list for Replens is not great: there are parabens (controversial regarding health risks), glycerin (upsets ph balance), and sodium hydroxide (essentially lye, that can mess with a good ph balance) to name a few.
What to use:
» I recommend using a compounded vaginal moisturizer that contains hyaluronic acid, aloe and vitamin E. Hyaluronic acid is naturally present in the vaginal lining (and other body tissues) and helps to maintain hydration. These compounded formulations can stick to the vaginal mucosa to provide hydration and protection. There is a hyaluronic acid vaginal gel available over the counter called Hyalo Gyn. This formulation does contain propylene glycol (anti-freeze) which for reasons previously discussed is not so appealing.

3. Vaginal estrogen therapy — Replacing vaginal estrogen topically actually restores what the tissue is missing. This works well if your vaginal dryness or pain with sex is related to low estrogen levels. In the beginning you will need to ramp up the treatment with daily use for the first two weeks to improve the tissue quality and natural lubrication and elasticity. It takes about six weeks to start reversing the changes associated with loss of estrogen, so wait six weeks before “trying it out” with your partner or yourself. You will need a prescription so ask your doctor about the different vaginal estrogen options.

4. Oral Estrogen Receptor Modulators (ERMs) — A recently FDA approved non-hormonal oral drug for painful intercourse due to estrogen deficiency is currently on the market. This could appeal to women who wish to avoid using any estrogen therapy at all or wish to avoid using vaginal treatments. Ospemifene or Osphena (brand name) is an estrogen agonist/antagonist. Similar to other drugs in the same family like tamoxifen and evista, this drug acts like estrogen on some tissues (such as the vagina and uterus) and like anti-estrogen in others (such as the brain and breast). You need to take one pill daily for 12 weeks to see an improvement in symptoms.

What to consider before using ERMs:
➔ Osphena should only be used when the cause of painful sex is low estrogen.
➔ Similar to hormone replacement therapy, Osphena will stimulate the lining of the uterus and could lead to precancerous or cancerous changes.
➔ Although the risk is low, Osphena can result in an increased risk of blood clots, heart attack and stroke.
➔ You may experience an increased risk of hot flashes.
➔ Osphena was not studied head to head against vaginal estrogen therapy which is the standard of care for treating vaginal dryness due to estrogen deficiency. It is unclear whether or not Osphena performs as well, better or worse than vaginal estrogen therapy.
➔ There currently are no long term studies to confirm safety with long term use.
My Recommendations:
» Osphena should not be used as first-line therapy. Until more studies are available, the risks of Osphena seem to outweigh the benefits. According to the drug-developers sponsored study, after 12 weeks of treatment only 14% of women using Osphena reported improvements in symptoms compared to placebo users. A similar percentage had adverse effects, like infection.
» If you are looking for a non-hormonal option to help estrogen deficiency related painful sex or vaginal dryness, I would consider compounded vaginal moisturizers and lubricants before trying Osphena.

5. Vaginal Laser Therapy — Vaginal Laser Therapy is the new kid on the block and patients seem to love this option. Several companies have developed vaginal rejuvenation laser therapy to address vaginal dryness, painful sex, vaginal laxity and even urinary incontinence concerns. CO2 lasers traditionally used for facial rejuvenation and wrinkle reduction are now used to stimulate collagen and elastin formation in the vaginal tissue without any estrogen or the need for continuous treatment.

This minimally invasive outpatient option can tighten the vaginal walls, restore tissue elasticity, natural lubrication and improve blood flow to strengthen the supporting ligaments around the bladder and urethra. Examples include the Femilift, the MonaLisa and IntimaLase. Each treatment lasts about 5-10 minutes each. You need a total of three treatments spaced 4 to 6 weeks apart. You will need one touch-up session after a year to maintain the benefit. This is a great option for those patients who don’t want to use estrogen hormone therapy, are not interested in having to continuously treat the vaginal tissue a few times a week or have not improved on standard therapy.

Fortunately, there are many options for treating this very common condition. Be sure to check with your gynecologist first to see what is causing the dryness and what options may be best for you.

The Take Away…

➔ There are several causes of vaginal dryness. It is important to be examined by a trained healthcare provider prior to starting treatment.

➔ There are several options available to improve vaginal dryness symptoms, especially if they are due to low estrogen levels.

➔ Lubricants, Vaginal Moisturizers, Vaginal Estrogen therapy, Vaginal laser treatment and non-hormonal estrogen receptor modulators are all available options.

➔ Talk to your gynecologist or healthcare provider to find out which options are right for you.