Just because we’re aging (I can say “we,” as I’m a septuagenarian) doesn’t mean we’re dead. Personally, I’m very interested in sex — and so is my girlfriend, who happens to be in her 60s. Unlike when we were 22, or 35, or even 45, as we age sex doesn’t just happen. It’s an example of “use it or lose it”. Ongoing enjoyment of sexual pleasure and activity requires planning, precautions, attention to detail and maintenance. In this blog I’ll give you specific advice for maintaining vulvo-vaginal health geared toward continuing access to pleasurable sexual activities. I’ll also talk about what to do if you’ve “let it go” and want to “get it back!” Everything to follow is evidence-based, and much is gleaned from recent medical literature.
Rosemary Basson, MD is a respected sex researcher from the University of British Columbia in Vancouver. She wrote eloquently in a recent editorial in the journal “Menopause,” and much of the next paragraph is quoted from her writing. Menopause influences physical, psychological, and interpersonal aspects of a woman’s life, and therefore can have profound effects on her sexuality. Estrogen levels fall and testosterone activity continues its slow decline. Women who are transitioning into menopause report hot flashes, sleep disturbances, changes in skin sensations, palpitations and headaches, and all of these influence their motivation to be sexual, as well as their ability to stay focused during sexual experiences. Postmenopausal women who are not receiving systemic estrogen therapy have permanently low estrogen levels, and if they’re not receiving appropriate intra-vaginal and perineal topical estrogen, atrophic vulvar and vaginal changes can make sexual activities difficult at best, and unthinkable for many.
Sexual response and freedom from dyspareunia (painful sex) are predicted by levels of estradiol (the main active estrogen molecule), but they’re not just about hormonal levels. Non-penetrative sexual activity, partner’s sexual skills and sexual function (e.g., can he get it up,) and presence/absence of partner pressure also contribute. Positive feelings for one’s partner, mental health, and past positive sexual experiences have also been identified as factors that increase resilience to sexual problems despite hormonal changes. Interestingly, a change of partner is apparently protective, and so are positive expectations for the current relationship. A couple’s emotional intimacy, respect, trust and mutual attraction are important.
Regarding hormones, the vagina LOVES estrogen. Those of you who have borne children may remember how “juicy” and expansible your vagina was during pregnancy. Pregnant or not, at younger ages both a woman’s estrogen and testosterone levels are replete. With aging, testosterone (T) levels exhibit a slow and steady decline and estrogen levels fall off the cliff, and the vagina can become dry and easily irritated, especially if your estrogen levels are low. Satisfying sexual relations are simply more difficult, and sometimes impossible in the face of seriously depleted estrogen.
The following are several clinical “pearls” taken from recent literature. The applicable conclusions will be summarized and referenced and, where appropriate, I’ll add my own brief comment. I hope they are both revealing and useful!
“Predictors of impact of vaginal symptoms in postmenopausal women.” Mary Hunter et. al. Journal Menopause, 2016.
Objective: This study aims to identify factors associated with greater impact of vaginal symptoms on the functioning and well-being of postmenopausal women. The conclusion suggests that special efforts should be made to identify and treat vaginal symptoms in postmenopausal women known to have depression or urinary incontinence, as these women may experience greater impact of vaginal symptoms on multiple domains of functioning and quality-of-life.
My Comment: A dry vagina is never comfortable, but is even more poorly tolerated in the presence of clinical depression or incontinence of urine.
“Vaginal estrogen use and effects on quality of life and urogenital morbidity in postmenopausal women after publication of the Women’s Health Initiative in New York City.” Prathima Setty et.al. Journal Menopause, 2016.
Objective: In the years after the 2002 publication of results from the Women’s Health Initiative study, there has been a reluctance to prescribe hormone therapy to symptomatic postmenopausal women, and confusion over its duration and method of prescription. Local vaginal estrogen may provide benefits without systemic effects. The study concludes that women who report dyspareunia (painful sex) and vaginal dryness are more likely to use vaginal estrogen. Women who do not use systemic therapy but who do use vaginal estrogen score significantly higher on the sexual quality-of-life scale than women not using vaginal estrogen.
My Comment: Vaginas like estrogen, and vaginal health and sexuality thrives in an estrogen-competent environment!
“The CLOSER (Clarifying Vaginal Atrophy’s Impact On Sex and Relationships) survey: Implications of vaginal discomfort in postmenopausal women and in male partners.” Rosella Nappi et.al. Journal of Sexual Medicine, 2013.
Objective: Postmenopausal vaginal atrophy is a chronic condition with symptoms that include vaginal dryness, soreness, itching, burning and dyspareunia. The CLOSER survey evaluated the impact of vaginal atrophy on physical and emotional aspects of sexual relationships between postmenopausal women and their male partners. It concludes that vaginal atrophy has a significant emotional and physical impact on postmenopausal women and their partners, including embarrassment, having sex less often, less satisfying sex, putting off sex, painful sex, reduced sexual desire, etc. Discussions about vaginal discomfort and erectile dysfunction and local estrogen therapy resulted in less painful sex and more satisfying sex.
My Comment: Women and their health care providers should be educated about the physical, sexual, and psychological benefits of local topical as well as systemic estrogen therapy.
“Quality of life and sexual function of naturally postmenopausal women on an ultralow-concentration estriol vaginal gel.” Salvatore Caruso et. al. Menopause, 2016.
Objective: This study aims to evaluate the sexual function and quality of life of naturally menopausal women affected by genitourinary syndrome of menopause (a/k/a vulvovaginal atrophy) who were treated with an ultralow concentration estriol vaginal gel (0.005%). The study concludes that estriol vaginal gel (0.005%) therapy significantly improves the trophism of the vaginal mucosa (cellular structure and physiology of the vaginal lining), sexual health and quality-of-life of naturally menopausal women. These results confirm that low doses of vaginal estrogen (both estriol and estradiol) must be considered as the first choice for the initial treatment of postmenopausal genitourinary symptoms.
My Comment: This is an interesting and valuable article. While it has been well known that a low dose of estradiol (as low as 0.01%) is very effective for re-instituting vaginal health, little research has been conducted on “the other estrogen,” estriol. Here we also have good evidence that a truly micro dose of the milder estrogen — estriol — is also helpful in reversing vulvo-vaginal atrophic changes.
NOW—On to more novel therapies for vulvovaginal atrophy: the use of intravaginal and introital fractional CO2 laser for recalcitrant atrophy, or in women declining to utilize estrogen therapy.
“An assessment of the safety and efficacy of a fractional CO2 laser system for the treatment of vulvovaginal atrophy.” Eric Sokol et.al. Menopause, 2016.
Objectives: The aim of the study was to assess the safety and efficacy of a novel fractional CO2 laser for the treatment of genitourinary syndrome of menopause (“GSM”). The study concludes that the fractional CO2 laser is effective and safe for the symptoms associated with GSM.
My Comments: In a classic example of technology outpacing research evidence, fractional CO2 laser therapy has been utilized for about 10 years to treat vaginal atrophy. We are finally starting to see decent research supporting claims that this therapeutic approach actually does have value. This paper adds to the literature on the subject accumulating over the past 5 years.
“Fractional CO2 laser treatment of the vestibule for patients with vestibulodynia and genitourinary syndrome of menopause: A pilot study.” Filippo Murina et. al. Journal of Sexual Medicine, 2016.
Objectives: Chronic vulvar pain and burning remains one of the most perplexing problems faced by practicing gynecologists. The aim of this study was to evaluate the effectiveness and safety of micro-ablative fractional CO2 laser to the vulvar vestibule in the management of patients with vulvar pain from vestibulodynia or genitourinary syndrome of menopause (GSM). The study concludes that the preliminary case series showed encouraging results using fractional CO2 laser treatment of the vestibule in women with vestibulodynia and GSM.
My Comments: This is the first article suggesting that fractional CO2 laser treatment may also improve vulvar vestibular — in addition to vaginal — health. Atrophic changes that lead to pain and dyspareunia are more difficult to treat in the vulvar vestibule than the vaginal canal. This paper also gives guidance on a specific treatment protocol. It is very valuable for the not-insignificant number of patients who have burning and skin separations each time they attempt intercourse.
“Fractional microablative CO2 laser for vulvovaginal atrophy in women treated with chemotherapy and/ or hormonal therapy for breast cancer: a retrospective study.” Tiziana Pagano et.al. Menopause, 2016.
Objectives: Breast cancer is one of the most common malignancies in women. Hormonal treatment and chemotherapy induce a transient or permanent menopausal status. Vulvovaginal atrophy (VVA) is a frequent debilitating symptom of menopause that is best treated with local or systemic estrogen formulations. Because estrogens drive the growth of a majority of breast cancers, most effective VVA therapies are precluded. The aim of this study was to evaluate the effects of fractional microablative CO2 laser on sexual function and relieving symptoms in women with breast cancer and VVA induced or exacerbated by breast cancer therapies. The study concludes that this treatment is associated with a significant improvement of VVA symptoms in women affected by hormone-driven breast cancer. The procedure has the advantage of relieving the treatment-caused symptoms without resorting to possibly contraindicated estrogen preparations, which have been the most effective therapy thus far.
My Comment: FemiLift™ and Mona Lisa Touch™ are the two most commonly used laser platforms for this therapy.