Dr Amy Tomlinson, with practices in Frisco and Buena Vista, treats painful sex, vaginal atrophy, vaginal dryness, and the genitourinary syndrome of menopause.
Are you having painful sex? Because it feels dry? Have you lost your stretch? Does it even feel like you may rip or tear with penetration? Are you perimenopausal or postmenopausal? This is sooooooo easy to fix with vaginal estrogen. And vaginal estrogen treatment has virtually no risks. Gynecologists used to call the problem “vaginal atrophy” or “atrophic vaginitis.” But over time, we have come to realize that this issue affects not only the vagina but also the vulva and the urinary system. Most of the vaginal problems are only issues during sexual activities. But the incontinence and frequent UTIs can bother people all day, every day.
What are the symptoms of the Genitourinary Syndrome of Menopause (GSM)?
Vaginal dryness during sex
Decreased lubrication during sex causing discomfort or pain
Tightening and shortening of the vagina
Light bleeding after intercourse
Burning with urination
Urgency with urination
Recurrent urinary tract infections
What is the Cause of Atrophy?
The tissues of the vagina, vulva, urethra, and bladder are exquisitely sensitive to estrogen levels. As estrogen levels drop, the tissue becomes thinner, weaker, and less resilient. As estrogen levels increase (even after years of atrophy), the tissue becomes plumper, moister, and more stretchy. Estrogenized tissue contains more collagen resulting in more plumping. A drop in estrogen levels is usually due to perimenopause or menopause. But this can also occur in breastfeeding women, who have high levels of progesterone and low levels of estrogen. Atrophic tissue appears thin, dry, and very light pink. Estrogenized tissue appears plump, moist, and more rosy-pink.
How does GSM affect the Urinary Tract?
The tissues of the bladder, urethra, and vulva also undergo changes depending on estrogen levels. When the bladder is not estrogenized, it becomes weaker and more likely to leak. People can experience increased levels of incontinence with coughing, laughing, or sneezing as well as feeling like they can’t make it to the toilet soon enough. When the urethra is surrounded by plumper tissue, it also becomes a better barrier to bacteria. Bacterial populations are greatly changed by estrogen levels. An estrogenized vagina contains a large population of healthy lactobacilli which do not cause UTIs. When estrogen levels drop, the pH levels increase, the lactobacilli population decreases, and “fecal flora” come in to colonize the vagina. This is a natural process–please don’t view this fact as gross–it just happens. It doesn’t depend on hygiene. Flatus / farting causes the bacteria of the colon / feces to be dispersed. This bacterial population is rich in bacteria like e.coli that can cause UTIs. Recurrent UTIs during the postmenopausal years can usually be cured with vaginal estrogen treatment–no antibiotics required.
When Can Symptoms Start?
As we encounter perimenopause and menopause, a process that typically begins in the 40s, estrogen levels fall. It is an inevitable part of getting older but it is not something that we need to “just deal with”. Most women reach menopause between the ages of 45 and 55. In my experience, many women start complaining of symptoms about 5 years following their final menstrual period. The symptoms can also be associated with breastfeeding.
Myths about the Menopausal Vagina
This is not a “use it or lose it” situation. In my experience, 99% of the time, vaginal symptoms can be completely resolved with treatment. Even if you haven’t experienced sexual activity in the past 20 years. Usually, the resolution of all of the vaginal symptoms takes just 2-4 weeks.
How Do We Treat the Genitourinary Syndrome of Menopause?
If dryness and discomfort during intercourse is your only symptom, then sexual lubricant is usually treatment enough. I recommend that you get into the habit of using lube every time. Don’t wait until you experience pain–it makes sex unpleasant. Astroglide is a good lubricant that is long-lasting. You can find it in most grocery stores and pharmacies. Please do NOT get KY–it doesn’t tend to last long enough. Vaginal moisturizers can be another option but they don’t seem to be very useful unless you are having sex nearly daily.
If your tissue can’t stretch to accommodate a penis, fingers, or toys in the vagina, then bioidentical estrogen treatment is the way to regain it. If you are having urinary incontinence or frequent UTIs, I also recommend estrogen treatment. Vaginal estrogen is applied directly to the vagina and it is NOT dispersed throughout your body so it does NOT increase your risk of breast cancer. There are 3 different bioidentical ways to deliver vaginal estrogen. There is cream that you apply vaginally 1-3 times per week, usually at night. A tablet the size of a baby aspirin is available to place vaginally 1-3 times per week. There is also a ring that you place in the vagina and leave there for 3 months at a time. Then you would remove the ring and replace it with a new one. It is similar to the vaginal ring used for contraception and you would not need a doctor’s visit for the change-out.
The other way to get estrogen to the urogenital tissue is to use “systemic,” body-wide treatment. I use bioidentical hormones in a skin patch, skin cream, pellet, or oral pill forms. Sometimes low doses of systemic hormones do not improve the genital tissue enough and we will need to add vaginal treatment as well. Systemic hormones can be especially useful if you have other bothersome menopause symptoms like hot flashes, night sweats, concentration changes, insomnia, or mood problems.
What if I want treatment?
If you are dealing with symptoms of vaginal atrophy, I’m here for you. A nice fact is that most people will NOT need to have an exam for this. We can also dive deeper into any other issues that you may be having. We can take care of this problem in-person or online via telemedicine. I have offices in Frisco and in Buena Vista and I take most insurance. I’d be honored to help you with this very fixable issue!