Magazine: Back-Issue Article
Vaginal atrophy - the taboo subject
Many women experience changes in the vagina and bladder as a consequence of the menopausal state of estrogen deficiency. In fact, most menopausal women who are not taking Hormone Replacement Therapy, and some who are, will have changes in the structure, blood supply, support, elasticity, sensitivity, lubrication and responsiveness of the vagina due to the lack of estrogen: vaginal atrophy. These changes can lead to dryness, discomfort during sex and at other times, vulval irritation and itch, increased susceptibility to infections and unpleasant discharge, bleeding which then causes concern about the possibility of serious disease and requirement for investigations and, in some couples, relationship problems due to difficulty being able to discuss the discomfort and avoidance of sex.
Changes also take place in the support, control and function of the bladder, as described on page 14, and, as reported in a previous issue, perhaps in the support, function and control of the bowel as well. We continue to have concerns that women are suffering in silence, not seeking help for these common, often distressing changes and, even if help is sought, often not receiving appropriate treatment. At Menopause Matters, we try to raise awareness of these common embarrassing problems so that women realise they are not alone, and so that they know that treatment is available.
In an attempt to further understand the problem, we often gather information from online surveys, where women can respond anonymously to questions about very sensitive subjects in the comfort of their own homes and from our surveys, valuable information has been obtained. A previous survey related to vaginal discomfort showed that over half of the 1,002 respondents reported vaginal discomfort. Of these, and despite 88% feeling that an active sex life was important to their relationship, only 20% had discussed their symptoms with a healthcare professional, 61% hid their symptoms from their partner, 60% felt less confident as a result of their symptoms and 42% made excuses not to have sex because of the discomfort, the commonly used excuses being headache, too tired and not in the mood. Sadly, despite effective, safe treatments being available, only 36% of women with vaginal symptoms were taking any treatment.
A recent online survey on menopausematters.co.uk asking specifically about vaginal dryness was completed by 1351 women, to whom we are very grateful. The results have shown that women are indeed still suffering in silence and that much more needs to be done to enable women to discuss these common consequences of the menopause and seek help.
19% were self classified as being premenopausal, 43% were undergoing “the change” and 38% were classified as having gone through “the change”.
Overall, a staggering 88% admitted to experiencing vaginal dryness. Interestingly this broke down to 82% in the premenopausal group, 86% in those undergoing the change and 94% in those through the change. The large percentage of women who are classed as premenopausal who have experienced vaginal dryness is surprising since before the menopause, the estroegn levels should be fairly normal and although there are situations before the menopause when vaginal dryness may occur due to low estrogen levels, such as in women who are breast feeding, or taking the contraceptive injection Depo-Provera, this is unusual. It may be that these women who classed themselves as premenopausal were in fact starting to have some changes in the function of their ovaries, ie were perimenopausal, which led them to be visiting the menopause matters website in the first place. Although vaginal and bladder changes of estrogen deficiency usually arise a few years after the menopause (the last period) or a few years after stopping HRT, in some women the changes do start early in the menopausal transition, especially in women who smoke who tend to have lower estrogen levels than non-smokers, and in whom there may be a direct detrimental effect of smoking on the blood supply to the vagina.
Vaginal dryness is often first noticed during sex when the first sign of estrogen deficiency changes may be reduced lubrication and indeed, 58% felt dryness only during sex, but 29% felt dryness all the time, and 8% at other times eg walking, cycling, yoga, horse riding, wearing clothes, sitting or when using toilet paper.
In this recent survey, overall 93% felt that a sex life was of some importance with 40% stating that a sex life is essential and 53% felt that it is fairly important. Only 7% felt that it was not important at all. This was similar whether women were premenopausal, going through the change or had gone through the change.
Of the respondents, 86% were sexually active and of those that were sexually active, a staggering 80% said that vaginal dryness had led to avoidance of sex with their partner.
18% admitted to vaginal dryness affecting self image, 33% affecting confidence, 56% felt that relationships had been affected, and 34% felt that vaginal dryness affected general wellbeing.
Of those that had experienced vaginal dryness, more women had seen a health professional for this reason than in our previous survey, with 63% doing so. Of these, 34%% said that the conversation was a little embarrassing but much better than expected , 32% had found the consultation neither embarrassing or uncomfortable and 11% had found the conversation really helpful and felt much better for having discussed the issue. The remaining 23% had found the consultation unsatisfactory with the main reasons being unhelpful advice or not being taken seriously.
In those who did not seek help (37%), reasons given were that 22% were embarrassed and 22% felt that it was part of ageing.
Treatments being used in those that had visited a healthcare professional included HRT (22%), vaginal estrogen (46%), moisturisers (26%) and lubricants (39%).
Of the group of women who had not visited a healthcare professional to discuss vaginal dryness, 51% had tried lubricants, 13% vaginal moisturisers, with 9% were using HRT and 2% vaginal estrogen.
To treat the underlying vaginal changes due to the lack of estrogen, the treatment that is most likely to revert the changes and restore the tissues to their former health is estrogen. If just treating the vagina and/or bladder symptoms of the menopause, then very low dose vaginal estrogen in the form of a very small tablet inserted with an applicator, vaginal cream which can also be applied to the outer area (the vulva), a pessary, or a vaginal ring which is replaced every 3 months can be used. These estrogen preparations are very effective and are not associated with risks which should be considered when using Hormone Replacement Therapy since they give a very low dose of estrogen which is concentrated in the vagina and bladder. Any vaginal estrogen preparation should be used for at least 3 months before the expected benefit will be achieved and should be continued long-term, perhaps even indefinitely. Many women are only given a short course of treatment and are disappointed when the symptoms may not be fully treated, or may return when treatment is stopped. We now recognise that these changes persist and gradually worsen without treatment and therefore treatment should be continued; menopausal vaginal changes are not like menopausal flushes and sweats which will reduce or even stop in most women at some stage.
Some women do not wish to use even the very low dose vaginal estrogen and may prefer to try lubricants or moisturisers, especially in the early stages of vaginal dryness. Lubricants tend to be oil based while moisturisers are mostly water based and the content of other ingredients varies between brands. In our recent survey, some women did find both moisturisers and lubricants gave a messy feeling (58% and 55% respectively), and slightly more (38%) noticed a lumpy discharge (clumping) with moisturisers compared to lubricants (20%). Small numbers of women noticed an unpleasant odour (14% with moisturisers and 10% with lubricants) and very few noticed discolouration (7% with moisturisers and 4% with lubricants). Reassuringly, 22% of women using moisturisers and 34% using lubricants had none of these problems at all.
All vaginal estrogen preparations should be prescribed by a doctor or prescribing nurse and of the non-hormonal products, Replens, Sylk and Hyalofemme can also be prescribed as well as being available to buy over the counter. Many other products are also available and it can be difficult knowing which to choose. Often trial and error is required to find the most suitable preparation for you.
The most important aspect of treatment is recognising that there is a problem and being able to discuss it, firstly with your partner and also, when necessary, with a doctor or nurse. Then you should be able to decide which type of treatment is likely to suit best depending on your symptoms, whether or not you also have bladder problems or other menopausal symptoms and taking into consideration your medical history.
If you continue to be embarrassed to even broatch the subject of vaginal dryness but do have a problem, why not show this article to your partner in the first instance, so that there is a better understanding of the problem. You could also use this check list to show to your doctor or nurse to start a discussion, or download and print off a check list at Vaginal Resources.
Vaginal dryness is a common consequence of the menopause. It is still a taboo subject and is still causing many women distress, loss of confidence, is affecting general wellbeing and is leading to avoidance of sex and relationship problems. It can be treated easily, effectively and safely. Start talking!
For more information and resources visit the whole section on Vaginal Problems.