Welcome to World Menopause Day Ladies! Its not a celebration. Its a reminder that, at an average age of 52, you can expect to lose your sexual confidence and suffer (in silence) from vaginal atrophy. You’ve come a long way baby…
Menopause is no fun at the best of times, but one of the unspoken side effects is Vaginal Atrophy . It does what it says on the label; thinning and drying out the lining of the vagina so that it becomes red, itchy and inflamed. Obviously, this does not make for great sex and if left untreated, it can lead to serious long-term urogenital problems, including incontinence.
Atrophy generally occurs around the time of menopause when oestrogen levels decline rapidly. Oestrogen is responsible for maintaining the production of vaginal fluid and keeping the tissue healthy and elastic, and when the ovaries stop producing it, less lubrication and high PH levels make the vagina irritable and more susceptible to infection.
After menopause, which usually happens at around the age of 52, it can take around eight years for the lining of the vagina to thin or ‘atrophy’ to the extent that sex becomes prohibitive. By then, a woman is sixty, and suffering, and giving up on sex altogether can seem like the easiest option, but this only exacerbates the problem because sex is actually one of the best ways of increasing local blood flow and keeping the vaginal tissues healthy.
How to treat it
Treatments for vaginal atrophy largely rely on replenishing declining oestrogen levels but despite the recognised beneficial effects of local oestrogen therapy, the CLOSER study (see below) suggests that British women are 50% less likely to receive treatment, compared to their counterparts in Europe and North America. Instead, British women are among the most likely to self-treat using over-the-counter (OTC) lubricants and moisturisers (68% cf. 58% overall)2, but these measures only provide temporary relief of symptoms and do not treat the underlying condition.
The best treatment for vaginal atrophy is local oestrogen. Topical applications are applied directly to the vagina while, in systemic hormone therapy, the hormones travel around the entire body5. Topical applications of oestrogen cream applied both to the entrance of the vagina and higher up inside actually plump up the tissue and this helps to relieve the discomfort and decrease inflammation. It should be used every night, for three to four weeks, and after that it can be continued at a sub HRT level of twice a week ad infinitum.
Women with these symptoms might also want to try boosting their Vitamin D levels as there is some evidence that it can help relieve vaginal dryness. It will certainly help the body to absorb more calcium to protect bones, which is particularly important for women after menopause. Alternatively, Professor John Studd DSc, MD, FRCOG advocates transdermal oestrogen ( rubbed on the ski of the arms) such as Oestrogel and says it is much more effective than vaginal oestrogen.
Topical oestrogen takes a couple of weeks to work, and once things feel less sensitive, a vaginal dilator is a great idea. Dr David Goldmeier who is a consultant in genitourinary and sexual medicine at St Mary’s Hospital suggests delaying their use until after the cream has taken effect. Dr Goldmeier uses Amielle Comfort Vaginal Dilators at his clinic, but I like the sound of Cool Water Cones. They were developed by the husband of a cancer patient who was undergoing radiation treatment and they are the only dilator that the American Cancer Society acknowledges for women during recovery. Unlike most dilators, they are soft, pliable and made from chemical free, 100% organic hydrocolloids. You run the cones under the tap and they become slippery and easy to insert, so you don’t need to use any additional lubrication. The company is US based but they can organise international distribution (www.coolwatercones.com/purchase) for about $35. With all trainers, women should start with the smallest size and keep it in for just ten minutes a night. A woman who goes up by one size each week should progress to one of the largest sizes in four to five weeks.
Sometimes, when the thinning of the vaginal lining is very significant, women require bigger doses of oestrogen than can be obtained from a cream. Although hormone replacement therapy (HRT) is still perceived negatively, HRT has been given the all clear by a panel of 40 international experts who presented their findings at the First Global Summit on Menopause-Related Issues in 2008. It is generally accepted that it is the progestogen element in HRT that causes side effects, not the oestrogen or testosterone, and the consensus among many medical professionals is that women in their 60s who do not want to take HRT long term can take moderate doses for a period of three months without any risk. Women who have had a hysterectomy can use oestrogen alone, and if they still have a uterus they can combine oestrogen with seven days of progestogen per month to prevent irregular bleeding. When the vagina looks pink (like the inside of the mouth), and sexual function is restored, they can then continue with local vaginal oestrogen at sub HRT levels for maintenance, and if things deteriorate, they can repeat the treatment.
The CLOSER Study
A robust, international study of over 8,000 women and their partners which 500 men and 500 women from the UK has examined vaginal atrophy’s impact on sex and relationships (CLOSER). The results of the study have been announced today to coincide with World Menopause Day and frankly, they make pretty depressing reading.
Vaginal atrophy is a condition that affects almost one in every two (45%) women but it has a greater impact on intimacy in Britain compared to other countries, according to new research announced today. Despite the fact that over two-thirds (70%) of British post-menopausal women with the condition say that their sex lives are suffering due to the condition, they are 50% less likely to access effective treatment, compared to the other countries in the survey. And British men were the least likely of all the men surveyed to want to talk about the problem – the typical British stiff upper lip. British women are most likely to worry about the future of their sex life (40% cf. 29% overall)
Two thirds of British post-menopausal women (67%) and their partners (65%) agree they are having less sex because of vaginal atrophy. Women from the UK are among the most likely to say that vaginal atrophy has led to the end of their sex life as they know it (39% cf. 30% overall)2. The main reason given for avoiding intimacy was pain during sex, with 61% of British women also saying that sex was less satisfying for them personally2. Vaginal atrophy is more likely to have a negative impact on British women’s self-esteem compared to women in other countries, with British women being most likely to have lost confidence as a sexual partner (41% cf. 27% overall)3,4 and to feel depressed about their sex lives (30% cf. 22% overall)3 and that they have lost their youth because of the condition (55% cf. 41% overall)2.
Communication barriers are greatest between British couples, with one in five British men being the least comfortable discussing vaginal atrophy3,4. Previous studies have demonstrated how vaginal atrophy is considered to be a taboo subject, even between women and their doctors1.
The CLOSER research shows that British women who had tried local oestrogen treatment for vaginal atrophy reported beneficial effects such as less painful sex (58%), more satisfying sex for their partner (42%) and themselves (40%), feeling closer and less isolated from their partner (33%), having sex more often (27%), and saying that they now look forward to having sex (26%)2; but too few women are seeking help.
“Despite the considerable impact on themselves, their partner and their relationship, three quarters of women with vaginal atrophy will not seek medical help1”, says Dr Nick Panay, Consultant Gynaecologist, Queen Charlotte’s & Chelsea Hospital, London, and Chairman of the British Menopause Society. In the Closer survey just 21% of British women have tried local oestrogen treatment and compared to their peers in other countries”.
they are 50% less likely to access these treatments
“CLOSER has shown that vaginal atrophy is clearly still considered a taboo subject in Britain – with couples in the UK reporting greater barriers in communication than anywhere else in the world. Many women are not seeking treatment because they are either too embarrassed to talk to their partners and/or healthcare provider, or they simply accept it as a natural part of ageing that can’t be treated”, continues Dr Currie. “It is important for couples to recognise the impact vaginal atrophy is having on their relationship and to be aware that there are effective treatments available from their doctor”. Communication barriers about vaginal health are greatest between British couples
One in five British men are uncomfortable with discussing vaginal atrophy, more than in any other country3,4, and as many as one in 10 men (10%) have felt sexually frustrated and thought about other women2. In addition, according to the CLOSER data, one in five men (22%) reported that vaginal atrophy has aggravated their own sexual health issues, such as erectile dysfunction2.
“The CLOSER study offers the first opportunity to examine the real impact that vaginal atrophy is having on the intimate lives of post-menopausal women and their partners”, explains Dr Heather Currie, Associate Specialist Gynaecologist at the Dumfries and Galloway Royal Infirmary, MD of Menopause Matters Ltd and Honorary Secretary of the British Menopause Society. “Most people have not heard of this condition, but vaginal atrophy is one of the most common symptoms of the menopause, and also the simplest to treat. The challenge remains that vaginal health in older women is still a taboo subject, and even doctors find it difficult to talk to their patients about it”.
The CLOSER research was an online survey conducted by StrategyOne (partnering with Ipsos MORI) between 13 December 2011 and 7 February 2012. The survey was completed by 4,100 post-menopausal women, aged between 55-65 who had ceased menstruating for at least 12 months and have experienced vaginal atrophy, and 4,100 male partners of post-menopausal women aged 55-65 who have ceased menstruating for at least 12 months and have experienced vaginal atrophy. The participants were located across nine countries: US, UK, Canada, Denmark, Sweden, Finland, Norway, Italy and France.3,4
The objectives of this research were to better understand the impact that vaginal atrophy has on intimacy and relationships, both physically and emotionally, and to find out how to encourage positive conversations among men and women about this topic. The research also looked at the positive impact that local oestrogen treatment can have on the sufferer’s relationship. The global results were first presented at the European Menopause and Andropause Society (EMAS) in March 20124 and the UK data was first presented at the British Menopause Society (BMS) Annual Conference in July 2012.3
1. Nappi RE, Kokot-Kierepa M. Vaginal health: Insights, Views and Attitudes (VIVA) – results from an international survey. Climacteric. February 2012;15:36-44.
2. Novo Nordisk Data on file. Vaginal discomfort: insights, views & attitudes. Women and partners survey: overall report (VIVA Study), 2012.
3. Domoney C, Currie H, Panay N, Maamari R, Nappi RE. The CLOSER Survey: Implications of vaginal discomfort in postmenopausal women and their partners. British Menopause Society (BMS), 22nd Annual Conference, July 2012.
4. Nappi RE, Maamari R, Simon J. The Partners’ Survey: Vaginal discomfort – insights, views & attitudes: The Viva Study. Poster presented at the 9th European Congress on Menopause and Andropause (EMAS), Athens, Greece, 28-31 March 2012.
5. Sturdee DW, Panay N. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509–522.
6. Hextall A. Oestrogens and lower urinary tract function. Maturitas. 2000;36:83–92.