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Revitalizing the Vagina


If only everything else in the
body was so simple to treat as the vagina. Despite this good news, just too
many women remain ignorant about the options and fail to address the subject
with their clinicians.


Untreated, the vagina and
vulva will atrophy eventually in all women, although often at a slower rate in
sexually active women. Nonetheless, vaginal thinning or dryness may not present
a problem unless there is pain with sex, or recurrent infections. The diagnosis
is simple, observation being adequate.


Following the principal of
starting with the simplest and safest therapies, the order of treatment is:

1.    Nonmedical approaches: Regular sex is a therapy. By promoting blood flow to the
genital area, vaginal health can be enhanced. This does not necessarily need to
be penetrating sex but external stimulation whether by massage, use of a
vibrator, or oral sex, will all be effective. Clearly, not even a partner is

2.    Nonhormonal therapies: There are vaginal lubricants like KY Jelly and Astroglide,
and vaginal moisturizers like Replens that can be found among numerous items in
the drug store that are effective in reducing symptoms temporarily. If the
moisturizers are used regularly beyond just for sexual activity, they may
provide longer-term relief.

Hormone therapies:
Beyond all other treatments, local application of estrogen is not only
highly effective but when used intermittently in low dose, remarkably safe. The
estrogen can be delivered in a cream, a ring, or a tablet. For example, a
quarter of an applicator of an estrogen cream once per week can be very
effective, deliver a truly low amount of hormone into the rest of the body, and
is so safe it is difficult to find any adverse effects reported in the entire medical
literature. Recently another hormone, DHEA, has been studied, but there is less
evidence for the use of this approach, and no FDA-approved product available.


There are many possible
reasons why discomfort may develop in the vulva after menopause, and low
estrogen is only one. Each has its own specific treatment.  The main lesson is that if there is
pain, irritation, itch, burning, redness, discharge or bleeding, or any
swelling, ulcer, wart, indeed any cause for concern, then the first step is to
see a gynecologist.

The most common reason for
thinning of vulval skin after menopause is low estrogen. Treatment involves a
low-dose application of estrogen cream to the vulva. There is another hormone
that also has a role in maintaining vulval health, and that is testosterone. In
fact, in my own experience, the application of intermittent low-dose
testosterone ointment to the vulva has given results far better than local
estrogen. This is not an approved indication by the FDA. Indeed, the FDA has
not approved any testosterone product for women. So this is one of those few
instances I recommend a prescription for a compounded product.


Beyond the effects of low
estrogen levels, the following are some of the potential causes for vulval

·      Infections, including yeast
(candida) and trichomonas

·      Sexually transmitted diseases,
including herpes genitalis and vulval warts (condylomata acuminata)

·      Trauma including sexual abuse

·      Irritation from tight underwear or
panty liners

·      Allergic reactions to ingredients in
deodorants, soaps, hygiene sprays

·      Skin diseases such as lichen sclerosis
or eczema

·      Skin complications of general
illnesses like diabetes, lupus erythematosis, or inflammatory bowel disease

·      Benign tumors or cancers

·      Complications of medications like
aromatase inhibitors (cause thinning of the skin) or antibiotics (increase
likelihood of yeast infections)

·      Excessive douching

·      Psychosomatic symptoms

Although this may seem a
disturbingly long list, the good news is that virtually every one of these
problems can be successfully treated. Women need to be educated not to just try
and live with the problem, but to seek expert care. A complete medical history
will have questions relating to all of the above possibilities, as will the
physical examination. In some instances, a small surgical biopsy may be
required to send a sample of the vulval skin for microscopic examination.


Most times answers are easily
found and successful treatment initiated. Far less often further specialist
opinion may be required.


Amongst the most grateful
patients in medical practice are women who have had pain with intercourse
completely relieved by a prescription for low dose estrogen.

Enjoy the week


Wulf Utian MD PhD DSc

MENOPAUSE – Why one size does not fit


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