Vaginal dryness is much more than a troublesome nuisance. But given the time constraints of office visits, many patients are understandably reluctant to discuss it, spending their limited time on more pressing questions. However, treating the emotional and physical discomfort that dryness can impose on a woman’s life is an opportunity to greatly improve her quality of life. For that reason, it is important to fully appreciate and communicate the potential for good that can come as a result of the right diagnosis and effective treatment for this correctable predicament.

Vaginal dryness ranks among the 10 most common problems occurring during menopause. According to a recent Gallup study,(1) as many as 13.9 million women 18 and older have experienced vaginal dryness. By 2014, this number is expected to increase to over 15 million as Baby Boomers continue to age. Over a quarter (26 percent) of women 50 and older experience irritating, recurring vaginal dryness, and 12 percent of women under 40 complain of it. Among those complaining of vaginal dryness, nearly nine out of 10 women (87 percent) describe it as at least moderately bothersome, with 51 percent finding it very bothersome.(2)

Vaginal dehydration, brought on by chemical or physical changes in the body can lead to symptoms that include painful sexual intercourse, itching, unattractive odor, and discomfort in even simple activities such as walking. If left untreated over time, this condition can exacerbate, resulting in much larger problems.

Bacterial vaginosis (BV), often mistaken for a yeast infection, is one of the more common and serious side effects, stemming from an imbalance of the pH level or alkalinity in the vagina, triggered by chronic dryness or in combination with other causes.(3) BV is known to increase the risk of sexually transmitted infections, including AIDS and is an important risk factor for obstetric complications such as prematurity, low birth weight, post-partum endometritis and miscarriage.(4) Table 1 (See Appendix) Yeast infections and abnormal vaginal discharge are also common in patients with recurrent vaginal dryness.(5)

Women need to be aware of the ways to treat vaginal dryness so that they are comfortable and can prevent potentially unhealthy conditions from developing. The best way to overcome vaginal dryness is to understand its origins and keep it under control, taking a holistic approach to alleviate recurrences.

What causes vaginal dryness?

A list of factors that contribute to vaginal dryness are shown in Table 2 (See Appendix). When the blood vessels that bring nutrients and oxygen to the vagina become constricted due to a number of possible circumstances, dryness ensues. These nutrients help maintain vaginal elasticity and health, ensuring that sufficient amounts of mucus and vaginal secretions maintain vaginal flexibility and elasticity.

With a dry condition, not only is sexual intercourse uncomfortable and even painful, but also the vaginal environment becomes more prone to bacterial and viral infections that may then be passed on to a partner. Frequent yeast infections may also occur, and patients often complain of off-color or off-odor vaginal discharge accompanied by itching and burning sensations. (6)

Changes in vaginal moisture can occur in response to hormonal cycles, for example during breastfeeding, menopause, or while on low-dose oral contraceptives. It can also occur in response to douching, pelvic radiation, prolonged use of tampons, advanced endometriosis and a variety of medications and other causes.(7)

Some cancer treatment medications, such as tamoxifen (Nolvadex) and – aromatase inhibitors such as Arimidex, designed to interfere with the aromatization of androgens to estrogens, may produce vaginal dryness. (8) Allergy medications and antihistamines can also dry out the body’s mucous membranes, causing dryness in the vaginal wall. Certain ulcer, antidepressant and high blood pressure medications can contribute to vaginal dryness.

Estrogen causes the vagina to thicken and moisten. When estrogen levels become depleted, hormone therapy (HT) with estrogen is the most-often prescribed treatment for vaginal dryness; but it may also slightly increase a woman’s risk for breast and/or uterine cancer. (9) Understandably, many women are opting to try other means of relief.

Step 1: A good medical history during the physical exam

Before doctors prescribe any treatment to alleviate vaginal dryness, it is critical to get a solid history from the patient. Has she been treated for endometriosis, for cervical or uterine cancer, has she experienced bleeding after intercourse or during times not associated with her menstrual period, or is she going through menopause?

Is she suffering from painful intercourse, relationship uncertainty, unusual or abnormal stress, fatigue from over-exercise, or psychological or emotional trauma? Does she have a family history of high blood pressure, diabetes, cancer, depression or other chronic illness? Is she eating a proper diet, exercising in moderation and maintaining a reasonable weight?

All of these factors help describe the patient’s life situation. The dryness condition is often caused by a number of factors beyond hormonal changes, from over-exercise to excessive sweating, chemical irritants such as soap or scented feminine hygiene products to over-douching (10), and especially high emotional or psychological stress (11).

Without knowing the patient’s situation, stage of life, circumstantial influencers, and history of suffering with this condition, one cannot diagnose and treat with success. Women in different age groups suffer from different problems. But the ultimate diagnosis may overlap age. Personal circumstance may also play a large role in the onset of dehydration. The healthcare practitioner must be patient, listen carefully to each situation and explain the various origins of vaginal dryness.

The physical exam is a very important aspect of evaluation. The vulvar area may show signs of irritation or redness. Scratching and irritation may make the vulva swollen and red which is often seen with yeast infections. Women with vaginal dryness are often less sexually active and as such are more sensitive in the vaginal area. For this reason, ask your doctor to use the narrowest speculum that allows for vision. It’s important to get vaginal cultures for both sexually transmitted infections and bacterial vaginosis and to have the discharge looked at under the microscope in the doctor’s office.

An odor, particularly one that is fishy, that is most typical of BV and is present in about half the cases. (Table x) The confusion occurs because the symptoms often overlap for the three most frequent diagnoses BV, yeast (candidiasis) and Trichomonas. Atrophic vaginitis caused by low estrogen levels is another common cause. The use of pH paper, a whiff of the wet prep slide and a microscope make the office diagnosis an easy one to make. Any other diagnosis will be uncovered by the culture.

Other causes include sexual abuse (either currently or in a previous relationship), trauma or depression, high stress over a prolonged period, confusion over sexual preference or an existing romantic relationship or any number of extenuating circumstances.(12)

Step 2: Look for additional risks and take aholistic approach?

Women suffering from cancer of the pelvic organs or breast cancer or from depression, diabetes, multiple sclerosis, uterine prolapse or even high blood pressure may be especially prone to chronic vaginal dehydration. (13 ? 15) Some women develop an allergic reaction to the latex in condoms, or they may have sustained some vaginal/cervical damage during childbirth. (16) They may complain of dryness due to a lack of foreplay, or from tampons and other feminine hygiene products, perfumes, shower gels, bubble baths or other chemicals, or even from over-douching.

In most women who have gone through cancer treatment, hormonal change causes the vaginal dryness. (17) Chemotherapy or radiation can damage the ovaries to the point where they no longer produce estrogen and progesterone. When estrogen levels decrease, the amount of vaginal lubrication naturally produced in the body also drops. Lower estrogen levels lead to a thinner, less elastic and more fragile vaginal lining. Hormonal changes due to chemotherapy or radiation tend to be dramatic and abrupt, leading to more intense symptoms.

Vaginal dryness can occur as a result of medications and treatments for other physical ailments, drug side effects or from previous surgical procedures. Any indications of past or current history of sexual abuse or extraordinary emotional and psychological stress should also be taken into account and explored as thoroughly as possible.

Treatment for vaginal dryness often doesn’t stop with a medical solution or prescription; it may be necessary to refer the patient to other healthcare specialists who can help them overcome more complex issues associated with the symptom. A holistic, thorough and caring approach to each patient’s situation is the best way forward.

Step 3: Find the right holistic prevention therapy

Treating the underlying cause with care and concern is by far the best approach. Besides hormone replacement (HT) therapy, most often recommended for those undergoing menopause, there are a number of natural and non-prescription approaches to help reduce the potential for dryness. (18)

Hormone replacement therapy is often effective. However, most vaginal preparations are absorbed into the bloodstream. If HT is used and the woman has a uterus, it will likely be necessary to add, at least occasionally, a progestin to achieve withdrawal bleeding and prevent endometrial hyperplasia, a pre-cancerous condition. Therefore, if either the clinician or the patient has concerns about the safety of estrogen, try more natural therapies.

First and foremost, avoid routinely using chemicals or products such as douches and perfumed feminine hygiene products. Eating a healthy, low-fat, low-cholesterol diet and getting plenty of regular exercise, for example 30 minutes a day, five times a week, and maintaining a healthy body weight or body mass index (BMI) are also good ways to stay on track. (19) However, excessive weight loss or exercise can cause or exacerbate vaginal dryness.

Seek professional counseling for psychological or emotional stress, past or current sexual abuse, and establish and are maintain a good emotional life with a strong level of support from friends and/or family. Stabilizing emotional or psychological suffering, stress and anxieties can go a long way toward ensuring longer-term physical health and well-being. If you are sexually active, make sure there is adequate foreplay to increase lubrication. As coital frequency increases, vaginal lubrication often increases as well.

Step 4: Treat the problem directly with a good vaginal moisturizer

In addition to treating the underlying physiological, emotional and psychological causes of dryness, there are a number of safe, over-the-counter treatments specifically designed to alleviate this problem. Among them, one of the best and longest acting is Replens Vaginal Moisturizer. Studies have shown Replens to be an effective compliment to vaginal estrogen creams in treating dryness and it works well without estrogen. (20) Lubrin is another product found over the counter.

Replens has been proven safe and effective for women suffering from cancer and taking medications including Tamoxifen. (21) It alleviates vaginal dryness safely and quickly for those with diabetes, after childbirth, during and after menstruation, and during sexual intercourse, particularly with a partner taking Viagra. A moisturizer differs significantly from lubricant, and should be used in different situations. Vaginal lubricants are short-term help used to ease discomfort with sexual intercourse and do not correct the vaginal dryness.

Replens is made with the bio-adhesive ingredient, Polycarbophil, that re-moisturizes and normalizes the vagina, replenishing and maintaining natural moisture for up to three days per application. In a clinical study of 89 peri- and post-menopausal women suffering vaginal dryness, the Replens polycarbophil-based lubricant was found by over 61 percent to be the preferred option over the two other options: estrogen hormonal replacement therapy, and KY Jelly, a non-prescription water-based lubricant. (22)

What else works?

Normally, the vagina is moist and slightly acidic (pH around 4.5). As estrogen levels decrease during menopause and other life events, vaginal fluids generally become less acidic, increasing the vaginal alkalinity and vaginal dryness occurs. Some of the problems associated with this condition include inflammation and thinning of the vaginal lining, vaginal bleeding, increased urge to urinate, leakage of urine, and vaginal infections.

K-Y Jelly, an inexpensive, water-based product is easily found in local stores but it will not correct the underlying problem, as a vaginal moisturizer such as Replens will.

Astroglide is another water-based lubricant found over-the-counter. (23) It comes in tubes or pre-packaged single-use amounts in an applicator that must be inserted by pushing the product up the vaginal tract like a tampon. Like K-Y jelly, it is an excellent lubricant but is short acting and does not moisturize. Silken Secrete is another short acting product.

What about alternative medicine, homeopathic therapy or vitamins?

Three homeopathic agents claiming to relieve vaginal dryness are Belladonna, Bryonia, and Lycopodium. Herbal treatments include dong quai or motherwort. There is no scientific research supporting or refuting the claims or effectiveness of any of these therapies. Ginseng does, however, have some limited scientific support for effectiveness in treating vaginal dryness. (24)

Some researchers believe adding certain items to the patient’s diet may help increase vaginal moisture. Additional research is necessary to determine the safety and effectiveness of these approaches, which include isoflavones (plant estrogens), found in soybeans and soy products, as well as black cohosh. (25) Black cohosh is a plant, also known as black snakeroot and bugbane, which may help offset some menopausal symptoms such as hot flashes but less is know about its potential benefit for alleviating vaginal dryness. It is not recommended for ingestion during pregnancy, nursing or while taking medication that affects the liver.

A mixture of soy flour (6 tablespoons) and flaxseed (2 tablespoons) has been shown to improve vaginal moisture and in one study, a soy-rich diet was shown to increase the karyopycnotic index among a group of menopausal women (26). Soy and flaxseed can cause natural, estrogen-like activity. This is covered in great detail in my book, The Soy Solution for Menopause (7). Women seeking to avoid estrogen therapy should consult their doctor first. It usually takes two to four weeks and may take up to six weeks to produce results.

Some women have tried opening a soft gel of Vitamin E oil and squirting it into the vagina daily for about a week, and after that once or twice per week. While adequate oral vitamin E intake has long been associated with healthy skin, there is little data to suggest that using E topically in the vagina is any more effective than any other oil (27).

In short, it’s best to stick with treatment, either prescription or over-the-counter, that has proven safe and effective. It is best to avoid self-treatments that have not been the subject of scientific and medical study over a long period of time.

Final Word About Dryness

Sjogren’s syndrome affects an estimated 1 million to 4 million people in the United States and is often defined by its two most common symptoms dry eyes and mouth. (28) Sjogren’s is an autoimmune disease that often shows up at age 40 or older, along with rheumatoid arthritis, lupus, scleroderma and polymyositis. With these diseases, inflammation of connective tissues is also common.

Since this syndrome is 90 percent more common in women than in men, the vaginal tissues are also affected and dehydrated, and damage can also occur to the lungs, kidneys and liver. Patients complaining of dryness of the mouth and eyes as well as the vagina may be reporting a history indicative of early stage Sjogren’s. There is no cure for Sjogren’s, but treatments can relieve many of the symptoms.

{mosbanner:id=1:right:0}Vaginal dryness is often associated with vaginitis or bacterial vaginosis (BV), which is a serious and common infection that can lead to other problems, not least of which is the easier transmittal of sexual diseases including AIDS (29). BV is often mistaken for a yeast infection and mistreated by women seeking quick relief without a doctor’s visit and medical prescription.

Among the most effective over-the-counter products to normalize the pH balance in the vagina to reduce the risk of BV is RepHresh. A normalized pH reduces the risk of vaginal infections. It also relieves irritation caused by dryness and infection, including itching and off-odor discharge. A recent study showed that RepHresh was not only capable of reducing the risk of BV coming back, but may also successfully be used to treat it (30). A suggested use of medications for treatment and follow-up of BV are listed in Table Y.

As you can see, the best approach to treating vaginal dryness is a holistic one, taking stock of each woman’s individual circumstances with thoroughness and sensitivity.

Some Helpful Websites:

MayoClinic.com. (2004). Vaginal Dryness. Retrieved 03-22-05 from http://www.mayoclinic.com/invoke.cfm?id=DS00550
MedicineNet.com. (2004). Vaginal Dryness. Retrieved 03-22-05 from https://www.medicinenet.com/vaginal_dryness_and_vaginal_atrophy/article.htm
DiscoveryHealth.com. (2004). Vaginal Dryness. Retrieved 03-22-05 from http://health.discovery.com/encyclopedias/2111.html
CancerConsultants.com. (2004). Managing side effects, treatment and prevention. Retrieved 03-22-05 from http://patient.cancerconsultants.com/supportive_treatment.aspx?id=23166
The Department of Health and Human Services, National Women’s Health Information Center (2005). Vaginal Dryness. Retrieved 03-22-05 from http://www.4woman.gov

APPENDIX:

Pregnancy Related

• Preterm Labor
• Low birth-weight
• Intra-amniotic fluid infection
• Premature rupture of the membranes
• Postpartum endometritis

Unrelated to Pregnancy

• Pelvic Inflammatory Disease
• Cervicitis
• Urinary Tract Infection
• Sexually Transmitted diseases including HIV
• Cervical dysplasia
• Postoperative infection

Medical Conditions

• Diabetes
• Sjogren’s Syndrome
• Cancer

Low-Estrogen Conditions

• Endometriosis
• Menopause
• Cancer
• Radiation
• Psychological (see below)

Chemical

• Douches
• Perfumes
• Soaps
• Bath or body products

Infectious Conditions

• Bacterial Vaginosis
• Yeast infections
• Sexually transmitted diseases (STDs)

Psychological

• Hypophalamic amenorrhea, stress
• Prior miscarriage
• Sexual assault, abuse
• Depression
• Trauma

Recommended Treatment for Bacterial Vaginosis (BV)

Antibiotic Treatment

• Metronidazole 500 mg orally twice daily x 7 days (2 g orally in single dose works slightly less effectively) or
• Metronidazole gel 0.75%, one full applicator (5 g) intravaginally daily x 5 days or
• Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime x 7 days (300 mg orally twice daily x 7 days or 100 g intravaginal ovules at bedtime x 3 days works slightly less effectively)

Follow-up treatment

• RepHresh Vaginal Gel every 3 days for at least 6 weeks to prevent re-infection.
• It is important also that the patient avoids douching, as this doubles the risk (Brown D. J Reprod Med.2004;49:781-86)

References

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2. The Gallup Target Market Report on Vaginal Dryness, (2004).
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