Vaginal dryness— why no one is talking or doing anything about it?

A new study published in the North American Menopause Society's Journal Menopause identifies the factors associated with the taboo of not talking about vaginal dryness. According to the study results, more than 50% of women do not report vaginal dryness and less than 4% of those affected ever use any of the proven therapies.  

It is no secret that as the estradiol level plummets during the transition through menopause, most women experience vaginal dryness and dyspareunia. The Study of Women Across the Nation (SWAN) recruited a multiracial/ethnic cohort of 2,435 women at baseline and followed them over 17 years, with each woman clocking in approximately 13 visits.

This prospective cohort study identifies the incidence of vaginal dryness and its role in the causation of dyspareunia and frequency of sexual intercourse.

When the women were enrolled in the study, 19.4% of women (aged 42-53 years) reported vaginal dryness. At the completion of the study, 34% of women reported dryness (aged 57 to 69 years).

Advancing menopausal stage, anxiety, surgical menopause, and being married all contributed positively towards vaginal dryness.

Higher endogenous estradiol level was inversely associated with vaginal dryness in women not taking hormone replacement therapy. Whereas concurrent testosterone levels, concurrent dehydroepiandrosterone sulfate levels were not associated with developing vaginal dryness.

The study also highlighted the fact that the frequency of sexual intercourse was not related to the degree of vaginal dryness or pain during sexual intimacy. So, women who were thinking that having more or less frequency of sex is a remedy for vaginal dryness have to look for some other proven therapy.

Besides, HRT was more effective in managing vaginal dryness in women who transitioned into menopause naturally as opposed to those who had surgical menopause.

Dr. JoAnn Pinkerton, NAMS executive director, says in a press release, “Studies have confirmed that although more than half of women develop vaginal dryness as they become more postmenopausal, most do not report symptoms. Some will try lubricants as they begin to develop pain with sex. However, if lubricants and vaginal moisturizers are not enough, there are highly effective vaginal therapies such as vaginal estrogen tablets, creams, the low-dose ring, and the new intravaginal dehydroandrosterone. It is shocking that less than 4% of women in the SWAN study were using these effective therapies by the end of the study period.”

She urged women to please report symptoms, and healthcare providers to please offer safe, effective therapies.

Abstract

NAMS press release 

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Endocrine Society issues guidelines for management of menopausal symptoms in breast cancer survivors

Women experiencing menopausal symptoms after receiving treatment for breast cancer should be managed with life-style changes instead of hormonal therapy says the first ever set of professional guidelines issued by the Endocrine Society.

Increasing incidence of breast cancer and improved survival have led to increasing number of women survivors who have a long life ahead, while experiencing the side effects of cancer chemotherapy.  

It is estimated that there are 9.3 million breast cancer survivors worldwide, who experience menopausal symptoms or clinical manifestations of estrogen deficiency.

The comprehensive review was published August 02, 2017 in Endocrine Society’s Journal of Clinical Endocrinology & Metabolism.

Premenopausal women diagnosed with breast cancer experience abrupt onset of estrogen depletion symptoms after treatment with chemotherapy. Just like women experiencing natural menopause these women develop vulvovaginal atrophy (VVA), vasomotor symptoms (VMS), osteopenia, and osteoporosis, CVDs and psychological symptoms like sleep disorders, mood changes and depression.

These women cannot be treated with Hormonal Replacement Therapy (HRT) like their counterparts with natural menopause.

The study’s first author, Richard J. Santen, M.D., of the University of Virginia Health System in Charlottesville, VA said in a News Release by Endocrine Society “Following breast cancer, women should generally not be treated with menopausal hormone therapy but should instead focus on lifestyle modifications such as smoking cessation, weight loss, and regular physical activity.”

“Pharmacologic agents are also available to treat women with severe symptoms. The most important thing to remember is that therapy must be individualized based on each woman’s needs and goals,” he further added.

The author and his colleagues reviewed randomized controlled clinical trials (RCTs), observational studies, evidence- based guidelines, and expert opinion from professional societies to formulate the guidelines.

1) Life style modification advised for all breast cancer survivors include weight management, regular physical activity, smoking and alcohol cessation, vitamin D and calcium supplementation and eating healthy diet.

2) Sleep and other psychomotor symptoms should be treated with mind-brain-behavior or nonhormone, pharmacologic therapy.

3) Vasomotor symptoms respond well to selective serotonin /noradrenaline reuptake inhibitors and gabapentenoid agents.

4) A variety of non-hormonal treatments are available for treating osteoporosis like bisphosphonates, including zoledronic acid (Reclast) and denosumab (Prolia).

5) Treatment of VVA is a grey zone, low dose estrogen applied vaginally is absorbed in blood and although the blood levels are within normal limits, it could still potentially stimulate occult breast cancer cells. Hence, it is not generally advised, especially those on aromatase inhibitors.

6) Intravaginal DHEA and oral ospemiphene is often prescribed to relieve dyspareunia but their safety is still not established in breast cancer survivors.

7) Vaginal laser therapy is being used, but still more data is needed to document its efficacy.

8) Researchers are looking into other therapies in near future like lasofoxifene, neurokinin B inhibitors, stellate ganglion blockade, vaginal testosterone, and estetrol.

9) The most important recommendation is treatment should be individualized according to need of each patient.