The dreaded dry vagina


[00:00:00] Hi everybody. So it's Friday and I'm here at the hospital waiting for a couple of laborers and I'm in the call room. I guess you guys can see a look. I have a light, which is very bright. This is what one of the call rooms looks like a little bit, um, lacking in decor, but perfectly acceptable and actually we're luckier than most hospitals. 

It's pretty decent. So I decided we're gonna talk about something really fun that I've been talking about for a while that I keep saying, and you guys keep asking about, which is vaginal atrophy. Wa wa, wa. You know what that is? So vaginal atrophy, it sounds dreadful, frankly. It is dreadful. The word atrophy literally means lacking nourishment, but in this case, vaginal atrophy or more appropriately vulva atrophy or what we now call vaginal vulva. 

But the whole word is atrophic, meaning it's not getting the same hormones and therefore it is less elastic. We will often use terms like, ah, [00:01:00] my vagina is so dry. Or as doctors will say, oh, do you feel like your vagina is dry? And that's actually not accurate because many of us will still get lubricated, but the actual walls of the vagina and the labia, the outside part of the vagina, the vulva, or the labia, will be lacking elasticity, and the reason that matters is in the set setting of intercourse, it will hurt. 

So you'll literally have pain. The fancy word for painful intercourse is dyspareunia, so you'll have painful sex. You still might be able to get lubricated, but it won't be as elastic, so it'll lead to difficulty for someone. Penetrate inside, it will lead to difficulty with actually being able to have the elasticity that causes the whole vagina to relax and soften and lengthen, which makes you then less lubricated because the the, um, tension it causes from that discomfort. 

And it also just means you're less likely to wanna have sex if you even wanted to have sex. When you're in menopause, which is very unlikely as it is, which we'll talk about it at another time. So [00:02:00] again, just to review, atrophy literally means without nourishment, which in our case means lack of nourishment from the hormones that happen in perimenopause and menopause as your hormones are decreasing or are done, and it leads to less e elasticity. 

The other times you might notice this would be when you're. So if you are breastfeeding in nursing, your estrogen levels are low, so your vagina will also be atrophic. So ladies, if you're wondering why in those first couple months after having had a baby, you not only have very little libido because you're exhausted and because your estrogen levels are low, but your vagina. 

Will hurt because of lack of elasticity, because it's a trophic, just like you're in menopause. And that makes sense because when you think about it, nature did not intend for you to have intercourse usually for that first year after you've had a baby, because that's how babies were spaced a year apart, meaning a year after the first delivery, you would get pregnant again. 

once you stopped nursing. The third time you might notice it is if you're on prolonged birth control pills. So sometimes the evenness that the birth control provides by [00:03:00] stopping ovulation and decreasing pregnancy, and it also can help your hormones with regard to mood, with regard to pain in your ovaries. 

So all the benefits of evening out your hormones can also decrease your libido and cause atrophy of your labia. So again, atrophy. Lack of nourishment. But in this case, what we mean is lack of elasticity. What can be done? Well, the simple thing to do is add lubrication, but that's really external. Meaning if you tell me, well, I use a lubricant, a lot of women will say, yeah, I mean, it's painful. 

Don't worry. I just use a lubricant, which really means to me, I'll just suffer through it, and I don't want you to suffer through it. Because I wanna be able to help fix it. So you certainly can use a lubricant. There's no harm in it, but it's not likely to help with the atrophy because again, the atrophy is not, oh, I just can't get lubricated. 

It is, I can't get elastic and the lubrication will only kind of coat the vulva. So I'm all for lubricants, I would certainly use, if you're using condoms, you have to make sure you don't use an oil based lubricant because the oil based lubricants can break the latex. If you're using non [00:04:00] latex condoms, you can actually use some oil based lubricants. 

Coconut oil. The kind we cook with is actually a great lubricant. And there's an one on the market that I'm not affiliated with, but I tell patients about it often called V magic, V like vagina magic, which I think is hilarious. Um, one of my partners said, all vaginas are magic. that is coconut oil mixed with essential oils. 

And the benefit of one of the oilier lubricants is that instead of just kind of making it a slick, slippery coating, it actually is a little bit more a malient, so it absorbs into the tissue better, better than just using a lubricant. Would be using the hormone that we are lacking in nourishment to add that back into the vulva in the vagina, to make the vulva plumper again and more elastic. 

And we're talking about estrogen. So there are two ways to use the hormones in your vagina. When I say two ways, I mean either straight out estrogen. Or D H E A S, which is converted into estrogen and testosterone in the cells, in the vulva, [00:05:00] in the vagina. We're gonna focus mostly on the estrogen because there's a lot more choices in that. 

I wanna say a couple of things about using vaginal estrogen. What I tell patients when I prescribe it, which is frequent. because this is what I say. As you get farther away from menopause, the vasomotor symptoms like sweating and flashing and all of those, um, really unpleasant symptoms actually will get better the farther you get from menopause. 

Meaning for many women by within five years after menopause, they're night flashes and hot flashes and. Will improve. So vasomotor symptoms will improve over time. Unfortunately, your vaginal atrophy will only get worse and worse and worse the farther you get from menopause. So the less the estrogen, the more atrophic you become, which means if you're planning on still having intercourse or. 

If you're having recurrent urinary tract infections, which is another side effect from having atrophy with or without intercourse, your urethra, the little hole up out of is also susceptible to estrogen and becomes less [00:06:00] elastic, which means bacteria can stick to it more. So that's another side effect from becoming a trophic. 

So how do we combat that by using vaginal estrogens? So the things that I tell patients first, , it's likely you're gonna need it if you actually are at all having intercourse or if you're having recurrent urinary tract infections. It's very common, don't worry about it. Second of all, vaginal estrogens really work and they work really well, provided you use them regularly. 

And depending on what type you use, you really have to stick to the regimen that is prescribed because if you stop sticking with it, then it won't work and it takes about six weeks to kick in. So you have to be patient when you start the downsides. First of all, insurance does not always cover it. Why? I don't know. 

Maybe because insurance companies don't care about our dry vagina. It's very upsetting, so insurance does not always cover it, and they can cost anywhere from 80 to $200 per dose. But one dose, when I say dose, one month's worth will often last two or three months, especially if you're using the cream. [00:07:00] So first down, It's not necessarily gonna be covered, which is ridiculous, right to your congress people and your insurance companies. 

Second downside, when you get it, the package insert will include information that is really for oral estrogen, meaning risks of heart attack, stroke. Blood clot and breast cancer, all of which are there, but are really for the oral data and for whatever reason, they put it on the vaginal boxes and they have not removed it. 

So when you read it, you'll be freaked out thinking, why did my doctor gimme medication that's gonna cause a stroke of heart attack, of blood clot and breast cancer, when in reality the data is very clear. Huge studies, repetitive studies that really confirm that. Estrogen is safe. Even in women who have had breast cancer, though, they have to be more particular about what formulations they use and what doses they use. 

So that is something they should talk about with their oncologist. Okay. But again, very, very safe. Third that I tell patients is, again, you have to use it regularly. If you don't use it regularly, it's not [00:08:00] gonna work. Nine out of 10 times when a woman comes to me and says, it didn't really work, and I say, okay, tell me again, how did you use. 

Did you wait it out for six weeks and did you continue to use it? Oh, no. Yeah, I didn't. It's not gonna work. Okay. Now that we've determined that it's very safe, that it's often very necessary, that it's annoyingly not covered by insurance companies, again, right to your congresspeople and that it works if you use it, we'll talk about the different types. 

So there is a ring that you can use that you put inside, or your doctor puts inside that can stay in for three months. Very easy because it's three months. You don't have to think about it. But sometimes men or women will notice it inside because it's a little bit thicker and bigger than the birth control ring, so it can be felt by the partner. 

Second, some people just don't wanna have to go back to the doctor every three months to put it in. Third is that it doesn't actually necessarily help the external, the vulva as much as the vagina and many women will. Dryness or the atrophy in both. Second choice you can use [00:09:00] are little tablets. Um, there's a brand called Vagifem that's a teeny little tablet that you just put inside. 

Sounds so easy. Has to be used twice a week is effective. The butts I would say are that because it's a small tablet that then has to liquefy in the vagina, you get a little bit of a watery discharge that many patients don't like, and again, it doesn't tend to work on the vulva as well as in the vagina. 

Third, Is a suppository of D H E A S that converts to estrogen and pro gester. Benefit being psychologically, it's not estrogen. It converts in the cells, and some of the oncologists will feel a little more comfortable with that in patients who have had breast cancer. The other benefit, I think, is that instead of being used twice a week, like the tablet, this suppository is actually used every day. 

The benefit being when you have to use something twice a week, it's really hard to remember. It's just a weird schedule to remember, whereas every day tends to be easier for many of us, and the way I look at it is if you forget once of the two times, then [00:10:00] you're only hitting it 50% of the time. If you forget once or twice of seven nights a week, then you're getting a higher percentage of it actually going to be able to work. 

Okay. The downside to that vaginal suppository is that you're using it every night, so you're getting a. Kind of nasty white discharge, which at least in contrast to having atrophy, dryness, and pain is better, but it's something you consider my kind of best all-time favorite pick is the cream, because it's a pain that you have to use it twice a week. 

It's a pain that you often will use an applicator with it. It does not always get covered by insurance, but it tends to have the best coverage. Literally physical coverage, not insurance coverage, meaning, You can put some of the cream inside the vagina, or you can rub some of the cream on the outside of the vagina and just the labia. 

Or even if your only issue is urinary tract infections, you can use a little dab on your finger and just rub it around the urethra itself without even putting it in the vagina. So the variability is what I like the most. Now, the cream is the one that patients with [00:11:00] breast cancer are actually discouraged to use the most because of the variability in the dose. 

Whereas if it's a tablet or a ring, it's a very meter dose that you will not mess up at all. Um, though again, you can talk to your doctor and if you're very careful about using only a very small amount of the cream, many oncologists will allow it. But again, you should talk to your specific oncologist and gynecologist about it. 

So again, we've talked about. Tablet, cream and suppository, all different ways to use it all. Um, have pros and cons. All can work. So while. Oral hormone replacement is something that's still kind of controversial with regard to the benefits and the risks. The vaginal estrogens are really not controversial. 

They're very helpful. They're very well tolerated. They're not so easy to use because you have to use them regularly, but once you get used to it because of the benefits, millions of women like it, and I think they're actually underutilized because not enough women know about it, or many women just tend to think. 

It's okay, I'll [00:12:00] just suffer. Well, it's just part of life that it's going to be dry, and the fact is it is very natural for it to be a trophic as we get older because it seems that nature didn't even tend us to be having sex past menopause. But lo and behold, here we are and we're in a position where we are unfortunately expected to be having sex. 

So, Again, that's something we're gonna talk about in the next week or two. Cause you've gotta talk about libido and how difficult that is as we age. Um, but with regard to your vagina, there are things that can be done. Okay. I didn't talk about those procedures that can plump up your vagina that they have before discussed and called vaginal rejuvenation, which I rail against because it just sounds so, I don't know. 

Frustrating and insulting to me to be able to, to be told that you need a rejuvenated vagina. Now there are a few products, and my practice actually does do one of the products that can help with atrophy and incontinence, meaning it's not used for cosmetic rejuvenation, but even that has a lot of downsides. 

Like it's a procedure that [00:13:00] is not covered by insurance and it can cost two to $3,000 and is not foolproof to work. So by and large, the vaginal estro. I think are the best bet because they have staying power. They work really well. I think in a perfect world, in conjunction with the procedure that produces collagen, the one I'm talking about that stimulates collagen and creates less at atrophy, that would be the ideal. 

But until insurance companies kind of smarten up and give a crap about us, I think most people aren't gonna be doing that. Okay. I hope that all helped. I'm gonna try to go deliver some babies. Okay. Bye.