Vaginal dryness, UTI, and Painful Sex in older women

As older adults age, especially women, a lot of changes start happening within them, mostly related to the body's routine functioning, physical changes and cognitive prowess. The body’s immune systems or their natural ability to fight off infections get weakened over time. There is also the female hormone oestrogen decline and deficiency seen in menopausal and postmenopausal women respectively.

Among many things, oestrogen helps the vagina with lubrication or natural wetness via its glands. In its absence, the vaginal tissue becomes thinner, dried and irritated. Oestrogen, with its slightly acidic nature, also supports the good bacteria or microbiome to continue to flourish, grow and become healthier. This ensured that the bad bacteria, even though being present in our large intestine and stools, did not manifest itself as a predominant illness since the good bacteria discouraged the bad bacteria’s growth. Without that acidic barrier, the bad bacteria can more easily grow and work its way up the urethra and urinary tract because the tissue between the urethra and vaginal opening loses that acidity too.

There is another factor of the weakening of pelvic floor muscles that makes it harder to completely empty out the bladder, and the bad bacteria breed well inside inactive urine.

All of these combined i.e vaginal dryness, its tissue thinning and prone to developing infections (vaginal and urinary) often leads to painful sex or intercourse. The doctors call this combination of complex issues - the Genitourinary Syndrome of Menopause (GSM).

Please note that while older women are at higher risk of developing infections, it also affects older men too. We learnt that in older women, oestrogen deficiency can lead to an overgrowth of the bad bacteria (E. coli), raising the risk of infection. In older men, kidney stones, bladder stones, enlarged prostate (benign prostatic hyperplasia, or BPH), and bacterial prostatitis can increase the chances of urinary tract infection. There are also the anatomical differences in play that cause more likelihood of infections in older women.

GSM is a term that encompasses all the menopause symptoms and signs associated with menopause (around 45-50 years of age) that affect the vagina, vulva, and urinary tract. It involves genital symptoms that include dryness, burning, itching or irritation of the vulva, along with sexual symptoms like lack of lubrication and discomfort or pain with sexual activity as well as urinary symptoms like painful urination, increased frequency or urgency of urination, and increased risk for urinary tract infections. Anywhere from 50% to 84% of postmenopausal women experience GSM and it may have a profound negative impact on the quality of life of postmenopausal women. Thus, women should be made aware of these problems and get treated with appropriate effective therapy.

But not everything is related to hormones. Cold and allergy medications and some antidepressants can dry out vaginal tissue too. Sjögren syndrome, an autoimmune condition that can cause a dry mouth and eyes, also can cause vaginal dryness. Older women can get urinary infection through a catheter, as other organisms may be present that can lead to a UTI. So, it is necessary to find out the root cause based on which, accurate treatment can be provided.

Urinary Tract Infections:

The clinical diagnostic criteria for symptomatic UTI (bacteria in urine that exhibits symptoms of UTI) can be any 2 out of these:

Fever or high body temperature,
worsened urinary urgency or frequency,
acute dysuria or painful urination,
suprapubic tenderness or pelvic pain,
costovertebral angle pain tenderness or back pain, along with,
delirium or confusion,
high pulse rate, and low blood pressure in the absence of fever in older adults.
Restlessness, hallucination, social withdrawal, agitation, nausea and vomiting are other signs of UTI in older adults.

Urine tests (routine, microscopic and culture) are usually the confirmatory diagnostic methods.

A positive urine culture with no more than 2 uropathogens (abnormal organisms) and pyuria (pus in urine) confirms the diagnosis of UTI.
Vaginal pH can also be measured along with painful sex medical history for confirmation of GSM along with UTI.

UTIs become more serious and repetitive as adults age. It tends to cause complications. Untreated UTIs could lead to complications like:

Confusion and delirium – Research has shown women older than 70 and those with dementia are at higher risk of suffering confusion from a UTI. This may be because the inflammation from a UTI has a better chance of affecting the brains of the older adult. UTI can spread from the urethra to the bladder to the kidneys and into the bloodstream, which can then spread into the brain (due to the blood vessels that supply the brain being weaker) and cause confusion that can lead to injury or distress. Also, they may simply be unable to communicate their symptoms. Up to half of people with dementia visit an emergency room in a given year, and the most frequent diagnosis is a UTI. Thus, delirium can be caused by UTI, or UTI can occur due to impaired maintenance of personal hygiene as a result of delirium, leading to unfavourable outcomes.
Bladder infection – Most UTI infections reach the bladder since the overgrown bad bacteria tends to work its way up the urinary tract from urethra. However, because UTIs are more common among older women, and may take longer to diagnose, the bladder could suffer more damage. An untreated UTI can lead to a bladder infection.
Kidney Infection – a UTI-related bladder infection will travel to the kidneys. A sudden, severe kidney infection (pyelonephritis) can cause permanent kidney scarring and damage.
Sepsis – A prolonged, untreated UTI could result in a potentially life-threatening form of infection called sepsis. This risk heightens if the infection has travelled to the kidneys.

Furthermore, apart from weakened immune systems and hormone deficiency, older adults have a higher risk of UTIs for many reasons, such as a history of these infections (recurrent infections), dementia, a prolapsed bladder (loose, hanging bladder), and bladder or bowel incontinence.
Conditions more common in older adults, such as Alzheimer’s disease, Parkinson’s disease, and diabetes can lead to urinary retention and lack of bladder control, which can affect your chances of getting UTIs.
Older people that wear adult diapers are also at a higher risk of this infection if they are not changed regularly enough. There is also a high risk of developing recurrent UTIs. Recurrent urinary tract infections (UTIs) are defined as 2 infections within 6 months or 3 within 1 year.

Treatment for UTIs in older adults varies depending on the symptoms.

Regular signs are generally managed by antibiotics or antifungal medications, but if confusion, agitation, and other related symptoms are involved, antipsychotics are used.
Advanced cases of UTIs, which can lead to things like kidney damage and sepsis, can be treated with an intravenous antibiotic regimen (requires hospitalisation).
It is important to note that early antibiotic treatment is common in bacteriuria (bacteria in urine) without symptoms of UTI, however, it is known to cause delirium therefore, the initiation of antibiotics should be delayed in asymptomatic patients until a confirmed diagnosis of UTI is established.
For Recurrent UTIs, Methenamine is a nonantibiotic prescription medication that is useful for UTI prevention. In some instances, taking daily low-dose antibiotics for 4 to 6 months is the most effective way to stop the cycle of infections.
If UTIs get developed after intercourse, taking preventive antibiotics after sex also helps.

To help reduce the risk of UTIs so one doesn't have to deal with them:

drink plenty of water, reduce or avoid caffeine and alcohol, change adult diapers as soon as they get wet, and wipe properly when finished in the bathroom (front to back).
UTIs also tend to be more common in warm weather so make sure to wear cotton underwear and regularly maintain personal hygiene.
For UTI prevention, vaginal oestrogen is very effective and is safe for most women as it reduces the risk by 50%-60%.
Taking a probiotic with Lactobacillus, a bacterium that is associated with good vaginal and bladder health will increase the local immunity.
Taking supplements like cranberry, vitamin C, and d-mannose can also be considered. These are not harmful but have not been proven to reduce infections. Cranberry should be avoided if discomfort is present since it can irritate the bladder.
Staying hydrated with at least 1.5 L of water daily will flush out the bad bacteria, but don’t overdo it. Aim for urine that is pale yellow to gold.
Older women can apply low-dose vaginal cream to support the tissue and maintain good bacteria.
Eating high-probiotic food, which supports good bacteria will be very helpful.

Vaginal Dryness:

There are several treatment options for vaginal dryness. Some, such as vaginal moisturisers or lubricants, are available without a prescription in most pharmacies. Others require a prescription; these include a vaginal oestrogen cream, tablet, capsule, or ring. The vaginal moisturiser, which is less expensive than vaginal oestrogen, works just as well as the estradiol tablets.

For vaginal dryness by itself, it is recommended trying vaginal moisturisers and lubricants.

Vaginal moisturisers add moisture around and inside the vagina. There are two types.
Internal moisturisers are inserted into the vagina, where they help build up vaginal tissue.
External moisturisers are made for the vulva or external genitalia.
Vaginal lubricants decrease discomfort during intercourse.
Sexually active women should use lubricants in addition to a vaginal moisturiser.
Water-based lubricants are preferred, though they don’t last as long as silicone-based products to avoid risk of infections.
Oil-based lubricants should be skipped for the same reason.

They can cause irritation and make condoms less effective. Vaginal lubricants and moisturisers do not contain any hormones and have virtually no systemic (body-wide) side effects. Possible local side effects include irritation or a burning feeling after application. Both lubricants and moisturisers are also available in preservative-free forms.

If GSM as a combination is present or the moisturisers are not helpful, then local oestrogen hormonal treatments are the best option.

Vaginal oestrogen creams and tablets are to be inserted a few times a week into the vagina.
Creams must be measured and can get messy.
Tablets are a good alternative in such cases.
Vaginal rings are to be placed in the vagina where they release a low dose of oestrogen over 90 days.

These treatments deliver less oestrogen than typical hormone therapy and have fewer risks. However, these treatments usually only work temporarily. The symptoms will typically return when the treatment is stopped. It often takes approximately 12 weeks (90 days) to experience a benefit with these medications (as the top layer of cells rebuilds and helps normalise the vaginal pH), although improvement in symptoms may occur sooner. Similarly, it also takes about 12 weeks for symptoms to return after the medication is stopped. As low-dose vaginal oestrogen is associated with few adverse effects, it can probably be used indefinitely, although there are no long-term studies to provide data about the effects over many years.

Vaginal moisturisers usually include hyaluronic acid and are formulated to allow the vaginal tissues to retain moisture more effectively. Moisturisers are applied into the vagina (as a gel or suppository) approximately three times weekly to allow a continuous moisturising effect. Be sure to check the label to ensure that you are purchasing a moisturiser and not a lubricant. Hand and body lotions and moisturisers should not be used to relieve internal vaginal dryness since they can be irritating to the vaginal tissues.

Lubricants are designed to reduce friction and discomfort from dryness during sexual intercourse. The lubricant is applied inside the vagina just before sex; it can also be applied to a partner's fingers or penis.

Products sold specifically as vaginal lubricants are more effective than lubricants that are not designed for this purpose, such as petroleum jelly.
In addition, oil-based lubricants like petroleum jelly, baby oil, or mineral oil can damage latex condoms and/or diaphragms and make them less effective in preventing pregnancy or sexually transmitted infections.
Lubricants that are made with water can be used with latex condoms and diaphragms.
Polyurethane condoms can be used with oil-based products.
Natural lubricants, such as olive, coconut, avocado, or peanut oil, are easily available products that may be used as a lubricant with sex.
However, it is important to know that, like oil-based lubricants, natural oils are not recommended for use with latex condoms or diaphragms, as they can damage the latex.
Water-based lubricants are a better choice if you use condoms or a diaphragm.

Vaginal oestrogen is one of the most effective treatment options for vaginal dryness if lubricants and moisturisers are not doing enough to relieve your symptoms or the dryness is associated with being prone to infections. These therapies restore the topmost layer of vaginal cells and increase elasticity and connective tissue when used on a regular basis.

Very low doses of oestrogen can be used to safely treat vaginal dryness when it is in the form of a vaginal cream or insertable tablet, capsule, or ring. A small amount of oestrogen is absorbed into the bloodstream with these vaginal forms, but when used regularly, the level of oestrogen in the blood is in the same range as in postmenopausal females who are not using vaginal oestrogen. As a result, there is a much lower risk of the side effects such as blood clots, breast cancer, and heart attack with vaginal oestrogen therapy, compared with other oestrogen-containing products (eg, birth control pills, menopausal hormone therapy).

Cream – Oestrogen cream is measured with an applicator and inserted into the vagina (if inserting the applicator is uncomfortable, one can also use their fingertip to apply and insert). The vaginal cream has the benefit of coating the vaginal tissues. The cream is usually inserted every day for two weeks and then twice weekly after that.
Tablet or capsule – The vaginal oestrogen insert is a small tablet or capsule that is put in the vagina. It comes packaged in a disposable applicator. It is usually inserted every day for two weeks and then twice weekly after that. Some people find it uncomfortable to insert the applicator at first, when vaginal dryness is at its worst. In that case, one should use another form of vaginal oestrogen.
Ring – The vaginal oestrogen ring is a flexible plastic ring one wears inside the vagina all the time. It can be replaced with a new ring every three months (90 days). The ring does not need to be removed during sex or bathing. It cannot be felt by most people or their sexual partners. In people who have previously had a hysterectomy, the ring will sometimes fall out.

To prevent or reduce the risk for vaginal dryness, the following could be helpful:

using vaginal moisturisers – it can be put inside the vagina to keep it moist
using unperfumed soaps and washes around the vagina
don't do douching in and around the vagina
do not put creams or lotions like petroleum jelly inside the vagina as it can cause an infection
do not use moisturisers that are not meant for vagina

Painful Sex or Sexual Activity:

Treatments for vaginal dryness may improve the issue of painful sex quickly, usually within a few weeks. If sex is not uncomfortable, one can continue to have sex as they treat vaginal dryness. Intercourse may help the vaginal tissues by keeping them soft and elastic. Using water-based lubricants before sex in and around the vagina, on the partner's penis, their fingers, or on a sex toy (if applicable) usually helps. One can also try to enjoy more foreplay so they feel more aroused during sex.

If the irritation and pain during sex don’t improve after 2 months of vaginal dryness treatment use, please consult your OBGYN. If sex continues to be painful despite treatment for vaginal dryness, it may be due to spasms in the vaginal muscles, for which, lubricated vaginal dilators can be tried which can gradually stretch the vagina. Specially-trained physical therapists can also help teach how to strengthen weak pelvic floor muscles and how to help relax tight internal vaginal muscles. If the symptoms do not improve with the above treatments, then we need to get it checked for vaginal infections, skin conditions, and allergic reactions that are not due to vaginal dryness.

GSM is characterised to have a drastic impact on the quality of life of affected women. GSM in older women can run the risk of becoming life-threatening if unrecognised and untreated. Thus, addressing these concerns first-hand is important to reduce that risk. Different treatment modalities have emerged to treat the condition's bothersome and life-changing symptoms. First-line treatment consists of non-hormonal therapies such as lifestyle changes, lubricants, and moisturisers, while hormonal therapy with locally administered intravaginal oestrogen products is considered the "gold standard" in more persistent cases.

Newer therapeutic approaches with SERMs (Selective Oestrogen Receptor Modulators) or laser technologies can be employed as alternative options, but further research is required to analyse their implementation in day-to-day clinical practice.