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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North American Menopause Society (NAMS) video series about important midlife health topics: New Treatment Option for Painful Intercourse

The North American Menopause Society (NAMS) is proud of its comprehensive video series for women on important midlife health topics. All the interviews in the series are hosted by NAM Board of Trustees Member and Immediate Past-President Dr. Marla Shapiro, a Canadian physician who led this exciting initiative. Dr. Shapiro is also the medical consultant for CTV News.

In this latest video, New Treatment Option for Painful Intercourse, Dr. Shapiro interviews Dr. Gloria A. Richard-Davis, NAMS Board Member, Division Director of Reproductive Endocrinology and Infertility at the University of Arkansas Medical Sciences and Medical Director of the Physician Assistant Program in Little Rock. Dr. Richard-Davis discusses a new nonestrogen, FDA-approved product (prasterone) and how it differs from other available products. She also answers questions about how to use it as well as how to initiate a conversation with your healthcare provider. 

New lower dose formulation of estradiol vaginal cream 0.003% relieves vulvovaginal atrophy.

getty images

Low dose estradiol vaginal cream 0.003% helps in relieving symptoms of vulvovaginal atrophy (VVA) in postmenopausal women says the results of phase 3 trial published September 18, in Journal Menopause.

This randomized, double blind, placebo control trial recruited a total of 550 sexually active postmenopausal women who were bothered by moderate to severe dyspareunia. The average age was 58 years. These women also had vaginal pH > 5.0 and cytology revealed only 5% superficial cells.

The women were randomized to receive either placebo or the 0.003% estradiol cream applied daily for two weeks, followed by three applications per week for 10 weeks. The women were assessed in terms of relief from dyspareunia, improvement in superficial cell cytology and decrease in pH.

After completing the treatment, women receiving estradiol cream reduced dyspareunia by 1.5 points vs 1.2 points in women with placebo. Estradiol also improved superficial cells by 10.1% vs 1.4% in placebo, vaginal pH reduced by 1.36 versus 0.53 for placebo.

Estradiol cream also relieved irritation, itching, dryness more effectively as compared to placebo (P < 0.01).

Mycotic fungal infections were significantly more common in estradiol group.

“Lower-dose estradiol vaginal cream (0.003%) dosed three applications/week is an effective and well-tolerated treatment for VVA-related dyspareunia,” the authors concluded.

The study was sponsored by Allergan, which is developing the new low dose 0.003% cream, the company’s other cream Estrace, which have 0.01% estradiol is already approved by the U.S. Food and Drug Administration for treating postmenopausal VVA.

Abstract 

More updates on vulvovaginal  syndrome of menopause:

FDA approves Prasterone (DHEA) for postmenopausal women experiencing dyspareunia

Applicator-free novel vaginal estradiol softgel capsule promising in relieving vaginal atrophy

NAMS updates  its position statement on HRT, clearing five critical areas of confusion

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

Plant based therapies and menopausal symptoms: A Systematic Review and Meta-analysis

According to data by North American Menopause Society (NAMS) about 6000 US women transition into menopause every day. With ever increasing life expectancy in western world (79.7 years) it is expected that by the year 2020 number of US women older than 51 will be 50 million and the corresponding statistics worldwide is 1.1Billion. [1]

Women who have undergone surgical menopause are more likely to use Hormone replacement therapy as compared to women with natural menopause. About 75% of women who undergo surgical menopause use HRT at some time, 50% of those with a hysterectomy only had used HRT and only 30% of women with natural menopause had used HRT.[2]

About 80% of women experience Vasomotor symptoms as they transition into menopause and according to the Study of Women's Health Across the Nation (SWAN)[3] these symptoms last average 7.4 years after menopause.

Many women opt for menopausal hormone therapy (MHT) to relieve the vasomotor symptoms, especially after the current research have shown it to be safe in women within 10 years of menopause and no contraindication. MHT have many adverse effects in older postmenopausal women (over age 60 years) and is not generally indicated.

Because of the concern for safety, many women are turning towards plant based herbal remedies often called as “Bioidentical hormones”. These are synthesized from soy and plant extract and modified to be structurally similar to endogenous hormones. A recent Systematic Review and Meta-analysis published in the recent edition of Journal of American Medical Association (JAMA)^[4] sought to determine the effectiveness of these therapies in relieving vasomotor symptoms and vaginal dryness.

Two independent reviewers extracted data from Ovid MEDLINE, EMBASE, and Cochrane Central, searching for eligible studies that were published before March 27,2016. A total of 62 studies were identified, including 6653 individual women. The main outcome studied were Hot flashes, night sweats, and vaginal dryness. The time range of therapy extended between 4 weeks to 2 years, the average being about 12 weeks.

Out of 62 studies, only 36 studies used plant based phytoestrogens, the rest used other herbal and Chinese herbal medicines.

As compared to placebo use of phytoestrogen was seen to decrease number of hot flashes per day (pooled mean difference of changes -1.31, 95% CI -2.02 to -0.61) and vaginal dryness score (pooled mean difference -0.31, 95% CI -0.52 to -0.10) but no difference was seen in daily night sweat score between the two treatment regimen. 

Dr. Oscar H. Franco, MD, of Erasmus University Medical Center in Rotterdam, The Netherlands, who is the lead researcher also and colleagues also attempted to determine the individual effects of plant based treatments like all forms of soy isoflavones, Black Cohosh and Chinese and non-Chinese medicinal herbs.

Red leaf clover and soy isoflavones were not found much effective in hot flashes. No definitive evidence regarding its active ingredients and concerns over safety and side effects were also important issues regarding its use in clinical practice.

Studies including Chinese herbal medicines and other herbal remedies lacked sufficient power to perform meta- analysis but the results were inconsistent and did not show any association.

The study had several limitations including the reporting of the hot flashes being itself subjected to recall bias, methodological deficiencies, limited generalizability, and inconsistent composition of phytoestrogen used.

The authors cautioned that the results should be interpreted in light of the limitations and further rigorous well designed randomized, placebo-controlled, double-masked trial with large women from different racial/ethnic background and menopausal status that could be followed up for years is required before any conclusion can be drawn.

Current evidence does suggest that the composite and individual specific phytoestrogen use was associated with moderate reduction in night sweats and vaginal dryness but has no effect on hot flashes.

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[1] http://www.menopause.org/docs/2012/cg_a.pdf?sfvrsn=2

[2] http://www.cdc.gov/nchs/data/misc/hrt_booklet.pdf

[3] http://www.swanstudy.org/

[4] http://jama.jamanetwork.com/article.aspx?articleid=2529629

[5] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3566363/

Menopause and the changing Vaginal Microbiome

With the increase in average life expectancy of women worldwide, it is estimated that 1.2 billion women will be menopausal or postmenopausal by the year 2030. About 85% of whom will experience at-least one menopausal symptom in lifetime. In US alone about 40 to 50 million women are estimated to suffer from vasomotor symptoms.

A recent review published in the forthcoming issue of Maturitas, The European menopause Journal  compares the  changes in vaginal microbiome with approaching menopause, the role of hormone replacement therapy in vaginal bacterial community  and role of probiotics in reinstating the homeostasis.

The vaginal microbiome plays an important role in women’s life, right from puberty to menopause. The diversity, abundance and composition of the microbial species in vagina varies dramatically. One of the original NIH-funded Human MicrobiomeProject (HMP) targeted sites for characterization of the microbiota was the vagina.

The relationship between the vaginal microbiome and menopause occurs predominantly through estrogen. During reproductive years, production of lactic acid and hydrogen peroxide by lactobacilli help maintain a strong barrier to pathogenic bacteria by maintaining a vaginal pH of 3.8 to 4.5. 

During the perimenopause women experience hormonal fluctuations, with decline in estrogen levels leading to a progressive decrease in acid-producing bacteria and pH rises >4.6 – this disrupts the vaginal micro-habitat and can lead to problems such as bacterial vaginosis. Normal flora has a dominance of various Lactobacilli, while in bacterial vaginosis (BV) microbiota is dominated by Gardnerella vaginalis and includes a number of anaerobic organisms.

In reproductive age women the microbial species in vagina can be grouped in five consistent groupings, referred to by Ravel et al as community state types (CSTs). Out of the 5 CSTs, the first four have higher proportion of Lactobacillus species whereas the fifth (CST IV) has lower proportions of Lactobacillus spp. and higher proportions of anaerobic organisms including Mobiluncus spp., and Atopobium vaginae.

As women progress towards premenopause and menopause, the composition of the VMB undergo significant change and play an important role in vulvovaginal atrophy. Postmenopausal hypoestrogenism causes a cascade of events that starts with thinning of the vaginal epithelium, leading to a smaller contribution of glycogen and higher alkaline pH that inhibits the growth of Lactobacillus.

Rebecca Brotman is an epidemiologist and infectious disease expert by training has worked and researched extensively on Vaginal Microbiome and its role in reproductive tract infection through various stages of women’s life. She is interested in intervention in VMB in context of meeting many of the challenges of premeopausal and menopausal life. 

  

In a study by Brotman R.M et al significant association was found between vaginal bacterial composition with menopause stage and signs of vaginal atrophy. A distinctive community state type CST IV-A was identified which was highly associated with signs of Vulvo Vagianl Atrophy (VVA) and was predominant in post-menopausal women. CST IV-A is a low Lactobacillus state and is known by a higher abundance of genera including Anaerococcus, Peptoniphilus and Prevotella, which could be playing a pivotal role in the clinical presentation of VVA.

It was also seen that compared to women with no VVA, the odds of CST of women with atrophy being classified as CST IV-A was 25 times more than being labellled as CST I.

This study provides a valuable insight into further research and studies to modulate and restore VMB homeostasis to understand and treat VVA in postmenopausal women.

It is well known that estrogen therapy is effective for the treatment of VVA and concomitantly, hormonal replacement increases the abundance of vaginal Lactobacillus species. Oral and vaginal probiotics holds considerable promise as a therapeutic modality for future in restoring the vaginal microbiome.  However additional trials are required before bacterial therapeutics can find its way into treatment armament species.

Several small RCTs have shown the effect of combination of ultra-low-dose vaginal estriol 0.03 mg in combination with viable Lactobacillus acidophilus to treat vaginal atrophy is superior to placebo. But, larger studies and meta-analysis are still awaited.

To date, a 2 strain combination of Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 have proved to be the most effective at restoring and maintaining a normal vaginal microbiota.

Science has yet not solved all the interactions between body and the microbiome. It is so complex that it will take many more years to understand the implications of this symbiosis and devising effective therapeutics.

References:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3248621/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3994184/

https://yeomanlab.com/projects/menopause-and-the-vaginal-microbiome/

http://www.ncbi.nlm.nih.gov/pubmed/24080849

http://www.imsociety.org/manage/infocus_export_members.php?infocusID=195

http://www.maturitas.org/article/S0378-5122(16)30124-4/abstract