Painful Sex? Vaginal Dryness?  Recently, I have seen several peri-postmenopausal patients with similar complaints. Starting after age 40, either the desire for sex wanes, or the desire is there, but sex is painful. Painful sex ultimately leads to avoidance, and there begins a vicious cycle. These are women in happy relationships, without depression or significant anxiety influencing the situation. (I have excluded the others for our purposes today.)While there is no magic answer to the problem there are several ways to approach this situation that may help. If you are also experiencing hot flashes, night sweats or insomnia, it is reasonable to "blame" your libido problems on several possibly compounding factors. The exhaustion that follows poor sleep, or following the daily multi-tasking of today's woman, familiarity of a loved partner, or new hormonal changes. Specifically the drop in estrogen we experience at several times in our womanhood. Post-partum women have low sex drive due to breastfeeding. The elevated prolactin level to maintain your milk supply necessarily causes low estrogen. Other times of low estrogen include following surgical removal of the ovaries, chemotherapy or radiation of the pelvis for cancer. The most common decrease, however, is noted in the year or two leading up to menopause. Low estrogen equals vaginal dryness. Vaginal dryness leads to painful sex. Even with an excellent lubricant (such as Astroglide), or daily use of a vaginal moisturizer (such as Replens) without your own lubrication and preparedness, sex can be uncomfortable and unsatisfying. What can we do about it? Vaginal estrogen therapy is a very reasonable treatment for most women. The dose is very low, so as not to be thought to increase your risk for breast or uterine cancer, therefore, no progestins need to be added, as little or no estrogen is absorbed into the bloodstream. In conjunction with oncologists, we often use local (vaginal) estrogen preparations in breast cancer survivors to allow for comfortable intercourse, and improve their quality of life. Local estrogen is not thought to increase one's risk for breast cancer or stroke as can systemic preparations. An additional benefit, I have learned, from my esteemed urology colleague, Dr. Sheldon Axelrod/mkmg.com, is the decrease in recurrent bladder infections and post-coital bleeding. (Since the posterior wall of the bladder anatomically sits on the anterior wall of the vagina, an increase of blood flow to one benefits the other.) There are currently three forms of vaginal estrogen preparations available, all used in a similar fashion. Vagifem, my current preference, is a small tablet (resembles a birth control pill on a little stick) that you insert vaginally at bedtime. Within the past year the dose has been further reduced from 25 mcg/night to 10 mcg/night, based on the randomized study showing evidence of similar response. This is used nightly, 14 nights in a row as a "priming dose", then 2 evenings/week for long-term maintenance. Estring, probably the lowest dose, is a plastic ring placed intravaginally that stays in place for 3 months and slowly releases local estrogen. It does not need to be removed for intercourse; is not thought to be felt by one's partner. You can replace it every 12 weeks on your own. Lastly, you can choose a vaginal cream: Estrace or Premarin cream; the dose is one gram ("one knuckle's worth") every night for 14 nights, then 2x/week for maintenance. Patients and physicians have their preferences, but, in my opinion the pill is least messy, therefore best tolerated. Whether you choose to try lubricant, increased vacation time, and/or adding a local vaginal estrogen when you notice vaginal dryness affecting your desire and comfort during sex, we can help. You can continue to be sexually active during treatment, (including masturbation), as this may help the vaginal tissues by keeping them soft and stretchable. preventing the tissues from shrinking. Sometimes, just discussing the problem, and hearing that you are in good company, can help. |
 |
|||||||
 
|
|
 |
|||||
    |
|||||||
