L had been a patient of mine for many years. A petite woman with perfectly fitting clothes, perfectly coiffed hair, and a perfectly proper manner. She had been a widow for many years and was now in her late sixties. I was so used to her seriousness, I nearly fell off my stool when one day she smiled and said, “I met a man, what do I need to know to have sex again?” I repeated, “You met a man?” as my brain registered what she said. For the first time, as we talked, she didn’t have pen and paper to take notes, but looked straight at me, engaged with me in a way I’ve never seen before. “I’m afraid sex is going to hurt,” she continued.

Comments like “my vagina feels like sandpaper!” and “I don’t want to have sex anymore, it’s too painful” are common complaints from my postmenopausal patients.

For some patients, they readily bring up the topic, even make an appointment to specifically discuss dyspareunia (painful intercourse). Recently, I had a 70-year-old patient tell me, “I used to enjoy sex and want to enjoy it again. You are probably thinking I’m too old to have sex, but I’m not. I hope you can help me.” She wanted a better quality life, including maintaining her sexual health, and I was happy to discuss it with her.

Others are much more shy and won’t say anything unless I bring it up. When I do a pelvic exam and see how atrophic and narrow their vagina is, I know it can’t possibly be comfortable to have intercourse. So I try to make a comfortable space for my patients to share issues revolving around their sexual health. Many times I hear, “I’m so glad you brought that up.”

There can be a variety of issues in the realm of sexual health, but for now, I will concentrate on probably the most common complaint: vaginal atrophy. Although women may say they have vaginal dryness, it is not simply dryness. If that were the case, just using a vaginal moisturizer or lubricant with intercourse would manage their symptoms. But atrophy includes thinning of the vaginal and vulvar tissue, decreased blood supply and decreased elasticity. As I tell my patients, “when you were younger, a baby could fit through your vagina, but your vagina can’t stretch like that now.”

What options are available?

The gold standard is vaginal estrogen. Replenishing the estrogen vaginally will thicken up the tissue and increase blood supply and lubrication. The added advantage is decreased bladder infections, which postmenopausal women are more prone to because of the atrophy. Vaginal estrogen comes in several forms: Estring (a vaginal ring that is replaced every 3 months), Vagifem (tablets that are inserted with an applicator - now available in a generic version), Imvexxy (vaginal suppository), and vaginal creams (Estrace and Premarin are the 2 common name brands, but there are generic options). Each has its own advantages and disadvantages including ease of use, options of titrating the dose, messiness, and cost. All have black box warnings regarding risks despite the minuscule amount of estrogen that actually gets into the bloodstream.

Another option fairly new on the market is Intarosa. It is a vaginal suppository containing DHEA, which has breakdown products of estrogen and testosterone. This product does not carry any black box warning, so for those patients uncomfortable using anything containing estrogen or have had breast cancer may consider this alternative. It is used daily and may take up to 2 to 3 months for a noticeable improvement.

Osphena is an oral alternative for vaginal atrophy. It is a selective estrogen receptor modulator (SERM), similar to tamoxifen (which is used to decrease the risk of breast cancer recurrence). As a SERM, it works like an estrogen in certain parts of the body only. For Osphena, it affects the vaginal tissue by increasing epithelium thickness and collagen content. It also can take up to 3 months for maximum effectiveness. Just like estrogens though, it is contraindicated for those with a history of blood clots.

There are also many non-hormonal vaginal moisturizers and lubricants available over the counter. Women need to be careful of the ingredients in some of the products as it may irritate them more (i.e. alcohol-based products). They also have to be aware that some lubricants cannot be used with condoms. Coconut oil is a natural product that helps both as a moisturizer and lubricant. A newer product on the market is Revaree, a vaginal suppository containing hyaluronic acid. The manufacturers claim their product increases blood supply and vaginal tissue thickness, but the supporting studies are fairly small. Hyaluronic acid has many medical uses, but its main function is as a moisturizer.

Lastly, a new non-hormonal option is vaginal lasers. The FDA recently published an article outlining concerns about the benefit of vaginal lasers; however, more studies are coming out which do show improvement in lubrication, epithelial thickness, and lowered pH. The CO2 laser works by disrupting the vaginal lining which stimulates new collagen growth. Typically, the treatment session takes about 5 minutes, is painless, and needs to be repeated 3–4 times over 4–6 months. Most women will notice a significant difference after the second treatment session. Beyond the initial treatment, an annual session is recommended if the patient begins to notice atrophy symptoms again.

I discussed with L her vaginal atrophy and how that could affect her being intimate with her partner. After reviewing all the options, she decided to try Vagifem. Months later, when I was finishing her exam, she blurted out, “I have one more thing to tell you, my boyfriend wanted to me to pass on a thank you from him for helping me…well, us…” And then she giggled. A seriously, teenage, hands hiding your face giggle. I couldn’t stop smiling the rest of the day.

Andrea Eisenberg has been an obstetrician/gynecologist in the Metro Detroit area for nearly 25 years. Through her many years in women’s health, she has shared in countless intimate moments of her patients, and shared in their joys, heartaches, secrets, losses and victories. In her writing, she captures the human side of medicine and what doctors think and feel in caring for patients. She has documented these stories on her blog. She has been a contributor to Intima, A Journal of Narrative Medicine and Pulse, Voices From the Heart of Medicine. Andrea is also a contributing author at BBN Times and a guest rotating blogger on KevinMD and Doximity. She is currently in Doximity’s 2018-2019 Authors Program.