Vaginal Dryness

Question

I am 57 and three years since my last period and am feeling fine except for one thing—my vagina hurts with sex. I’ve tried all of the over-the-counter-things I’ve heard about from my friends and pharmacist. I hate pelvic exams so I’ve not yet been to my doctor about it! Any suggestions?

Answer

Thank you for your question. It is one we get from a lot of women although two thirds of menopausal women have no problems with intercourse. I guess you’re in that unlucky third.

First of all, the vagina is made of mucosal like the inside of our mouths. That makes it normally moist, stretchable and not too tough. During our menstruating years the vaginal mucosal is supported to be between two and three cell layers thick. The outer layer can make it a bit tougher—that layer grows in response to high levels of estrogen. The second layer is called “intermediate” cells and both estrogen and progesterone stimulate the cells to that layer. It is the average of cells in menstruating women. However, with lower estrogen levels after menopause and no progesterone that level may disappear and only a basal layer is left. This basal layer is associated with symptoms during sex—it is thin, tends to bleed easily and looks red and shiny to a doctor doing a pelvic exam.

Now, we need to talk about the normal process of changes in the vagina during the lead up to sex. As we get “interested” more blood flow goes to the vagina and surrounding tissues. These make it more stretchy and elastic. The tissues also ooze a clear liquid that provides some lubrication of the vagina. The cervix also provides some stretchy mucous. Together these changes make intercourse both possible and pleasurable.

However, if our partner is too quick, begins to try to have intercourse before we have relaxed and become lubricated, we are likely to feel dry. Men’s sexual responses tend to be much more centred on the penis than ours are on the vagina and clitoris. For us, skin in general, lips, ears breasts and other mysterious places have sexual responses that are necessary for lubrication. A big inhibitor of lubrication and interest is insecurity (about someone barging in, about our bodies, about gas in our tummies, or about our lover). Everything has to be “right” before we relax into pleasurable sex.

The other ingredient is the body’s memory. If you have ever experienced painful sex, there is an unconscious part of you that will try to guard against a repeat performance. The net result is dry! And it becomes a self-fulfilling prophecy! You must work with your partner, explain how you feel and ask for just touching and for the ultimate in gentleness.

Right now I’d recommend that you think about these things and work out how to ask your partner for what you need. If you use water-soluble lubricants, have trusting and gentle sex and still you are uncomfortable, you may need some hormonal help. This therapy should always be local meaning in the vagina and never systemic (something rubbed on the body or worn as a patch). Happily there is a cousin of the strong estradiol that dominated during our menstrual lives that is less likely to cause sore breasts, fluid retention, and risk for endometrial stimulation. It is called Estriol and is often written as E3. It can only be obtained from a compounding pharmacist. However, there is good evidence that it is both safe and effective from a randomized controlled trial in women with such severe shrinking of the tissues that the urethra (urine tube) is so short that they got many bladder infections (“cystitis”). Estriol in a dose of 0.5 mg applied with the pointing finger in the vagina nightly for a week, then every other night for a week and then once a week is both safe and effective. Other options are an estradiol releasing rubber ring called Estring that is worn all the time and lasts for three months. However, it costs about $50.00 a month. But it is a little less messy than the estriol cream. The choice is yours.

No matter what even strong estrogen you may take, if sex is rushed, or not gentle or with a partner to whom you don’t feel close, you will feel dry.

I hope this is helpful for you.