Vaginal Dryness and/or 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.

Such women tend to experience 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 (if they are sexually active). Anywhere from 50% to 84% of postmenopausal women experience these issues 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. So, it is necessary to find out the root cause based on which, accurate treatment can be provided.

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 urinary symptoms 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.

In older women, vaginal dryness is often associated with Urinary Tracts Infections (UTIs) that cause painful sex in sexually active females. This combination of genital and urinary symptoms in older women (who are menopausal and postmenopausal) is called Genitourinary Syndrome of Menopause (GSM). GSM is characterised to have a drastic impact on the quality of life of affected women. 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.

Vaginal dryness can cause daily life restriction and negative life quality associated with it. Some senior women might not feel comfortable bringing up the symptoms of discomfort to caregivers or loved ones, or they may not experience any urinary symptoms, so it's important to be aware of and watch for these symptoms specific to seniors. It is also important to allow the safe space for older women to talk about their concerns and for the doctors/physicians to proactively check or ask about these symptoms with the women. This will help them to have better quality of life and outcomes.