Many women suffer in silence during painful sex, unaware that there are treatment options for vaginal dryness, and its effects are far-reaching.

Vaginal dryness affects a woman’s health, intimate relationships and quality of life. I know because it affected my health and love life.

It occurs most often after menopause, but it can also develop during breast-feeding or at any other time your body’s estrogen production declines.

Estrogen, important for maintaining vaginal health and lubrication, is the hormone that actually plumps up the cells in the vagina. When estrogen levels decline, the vaginal walls can become thinner, less elastic and dryer.

The result is vaginal dryness, also known as vaginal atrophy (VA), which is a chronic progressive condition contributing to painful intercourse.

According to the North American Menopause Society (NAMS), up to 75% of menopausal women may experience vaginal dryness as they age. I was not alone, but I must admit no one was talking about it, other than my extremely supportive husband.

Are you suffering from vaginal dryness?  Or is your partner?

Symptoms include:

• Vaginal dryness
• Burning and itching
• Irritation or soreness
• Pain and bleeding during intercourse or urination
• Shortening and tightening of the vaginal canal

When a woman experiences pain during intercourse, it is no surprise that her desire for sex may decrease.  A physical condition such as vaginal dryness can avalanche into an emotional response affecting both relationship and self-esteem.

With severe vaginal dryness, the tissues of the vagina become dry and sometimes fragile and inflamed. As a result, they are more prone to injury, tearing, and bleeding during sexual intercourse or even a pelvic exam. Over time, especially in the absence of regular intercourse, the vagina may also become slightly shorter and narrower. The resulting discomfort can intensify to the point where sexual intercourse is no longer pleasurable or even possible.

Not only does the physical act of intercourse become a challenge, the increased emotional stress can be a double whammy for a healthy sexual relationship.

The Partners’ Survey, which is a part of a larger global survey called CLOSER Research (Clarifying Vaginal Atrophy’s Impact On Sex and Relationships) sponsored by Novo Nordisk, revealed that 65% of men worried that sex would be painful for partners, and almost a third of both men and women reported that they discontinued having sex with their partners as a result of discomfort.

This survey, which included 4,167 post-menopausal women ages 55 to 65, found that 57% of women avoided being intimate, and 65% said they lost their libido.

The good news is the majority of the 4,174 men in the survey were concerned about what was going on with their partner. Unfortunately, this taboo subject has partners turning off the lights at night rolling over, confused and frustrated.

Margery L.S. Gass, MD, NCMP, NAMS Executive Director says,

“This topic is so sensitive that, according to the International Menopause Society, 70% of women say their healthcare professionals have only rarely or never raised the subject with them.”

James A. Simon, MD, NCMP, FACOG, Clinical Professor of Obstetrics and Gynecology at The George Washington University School of Medicine in Washington, DC, says,

“In my experience treating patients, most women are not comfortable talking about vaginal symptoms, especially related to pain and discomfort. The word ‘vagina’ is somewhat taboo, so it’s no wonder no one talks about vaginal atrophy.”

Taboo or not, vaginal dryness is manageable and treatable.  The North American Menopause Society recommends:

• Vaginal Lubricants: Decreases friction during intercourse.  There are many over-the-counter (OTC) water and silicon-based options. Water-based lubricants are popular and easy to wash off. Silicon-based lubricants tend to last longer, but are not as easy to wash off.
• Vaginal moisturizers: Non-hormonal OTC, generally used twice a week.  Moisturizers are absorbed by the skin and adhere to the vaginal lining, keeping it moist.
• Regular sexual stimulation: Intercourse promotes blood flow to the genital area, helping to maintain vaginal health.
• Developing expanded views of sexual pleasure: If vaginal penetration (intercourse) is difficult or uncomfortable, consider so-called “outercourse” options such as extended caressing and massage.
• Local prescription therapy: For vaginal dryness and discomfort that does not respond to over-the-counter lubricants and moisturizers, low doses of local vaginal estrogen therapy are very effective and safe. Local estrogen increases the thickness and elasticity of vaginal tissues, restores a healthy vaginal pH, increases vaginal secretions, and relieves vaginal dryness and discomfort with intercourse.
• Systemic prescription therapy. Low doses of systemic estrogen in the form of a pill or skin patch or gel used to treat hot flashes are also effective for treating vaginal dryness, although some women might benefit from adding local treatment to their systemic treatment to relieve discomfort. If only vaginal symptoms are present, local therapy as described above is recommended.

During my menopause transition, I was very aware that vaginal dryness was a common symptom and assumed this was a natural part of aging.  I made assumptions that if my skin was aging, why would my vagina be any different? Then, I became aware of the many options for treatment.

I started out using OTC silicon-based lubricants and that worked for a few months.  It solved the friction problem, but not the pain.  Then, I tried vaginal moisturizers and the pain was relieved for a few more months. However, since vaginal dryness tends to be a progressive condition, the situation only got worse for me.

Per the Partners’ Survey, 56% of women and 57% of men whose partners used local estrogen therapy reported that sex was less painful.  This was true for me.  Painful sex disappeared once those vaginal cells were plumped up with local estrogen therapy, restoring my love life.

Recently, I asked Wen Shen, MD, Assistant Professor of Gynecology and Obstetrics at Johns Hopkins University School of Medicine, about the safety of vaginal hormonal treatment:

“Vaginal estrogen comes in very low doses, as light as ten micrograms used twice a week.  There have been premarketing studies that show women who use vaginal estrogen do not increase their systemic estrogen levels above the post menopausal level.  After treatment, the levels actually go back down again to really low levels.

The vaginal skin and bladder are very well treated with vaginal estrogen, and they have more elasticity and thickness, so that the vagina can serve as a sexual organ again and the bladder can be less irritated.”

It is important to discuss vaginal dryness with your healthcare provider to confirm that you are not suffering from a vaginal infection.  If left untreated, it can lead to long-term complications in some women.

According to Dr. Shen:

“Vaginal dryness is one of the easier symptoms of menopause to treat that carries the least amount of risk.”

I was so happy there was a solution to vaginal dryness that I started talking about it with my girlfriends.  Many confessed that they too suffered from extreme dryness during intercourse and were losing interest in sex, leaving their partners feeling confused and distanced.

My friends and colleagues in the menopause community started calling me “Vagina Girl” because I always asked, “How’s your vagina?” It was perfect when asked to join the GLAM TM (Great Life After Menopause) team to bring awareness to vaginal dryness.

My message to woman, and to the men who love them, vaginal dryness is treatable. Talk to your healthcare provider. If you are menopausal or suffering from hormonal changes, you don’t have to suffer in silence.

Vaginal health is more than sexual health – it is good women’s health.

By Staness Jonekos, Co-Author The Menopause Makeover

Medical reviewer: Wendy Klein, MD, FACP

Disclosure: I am a member of GLAM™ (Great Life After Menopause), a women’s health initiative sponsored by Novo Nordisk. www.VaginalDiscomfort.com

Are You Suffering from Vaginal Atrophy?

When I went through menopause everything about the experience was still in the closet. Five years later, we have an official month celebrating menopause. Today we are freely talking about hot flashes, weight gain, aging and no longer feeling sexy.

Big progress in half a decade, BUT there is one area of women’s health that is so taboo many health care providers aren’t talking about it. Up to 75 percent of postmenopausal women may experience symptoms of it, yet only 25 percent seek medical help.1

Many of us suffer in silence from this natural part of aging, yet are too embarrassed to discuss this condition. What is it?

VAGINAL ATROPHY

Blushing? Uncomfortable? Squirming? Wondering if YOU have it? Asking yourself if your partner has it and that is why she is not interested in sex anymore?

An estimated 1.2 BILLION women worldwide will have reached menopause by 2030 – so it is time we start talking about vaginal atrophy.4

Good news! Novo Nordisk, a leader in women’s health, invited my favorite menopause influencers and me to form a team committed to raising awareness about vaginal atrophy (VA). We call ourselves GLAM™ (Great Life After Menopause), and we even have a logo and website.

As a GLAM™ (Great Life After Menopause) spokesperson, I will be able to share the latest science on VA, discuss symptoms and give you tools so you can proactively discuss VA with your health care provider.

Do you suffer from VA? 2

• Vaginal dryness
• Soreness
• Itching
• Pain and bleeding during intercourse
• Irritation
• Painful urination

GREAT NEWS! VA is treatable. Visit vaginaldiscomfort.com to complete the vaginal atrophy symptom identifier and bring it to your next medical appointment. You can use it to start the conversation.

In contrast to hot flashes, which generally settle with time, VA symptoms tend to progressively get worse.1

I know, because I suffered with VA, and I kept hoping it would go away. I thought the dryness was a normal part of aging and I should learn to live with the consequences. Unfortunately it was affecting my love life. After studying the latest research I was thrilled to learn there were treatment options.

If you think you may be suffering from VA, you are not alone! I will share information, conduct online chats, be available via Facebook and Twitter — I WILL BE TALKING ABOUT VAGINAS and VAGINAL ATROPHY! I invite you to join me in breaking the taboo, let’s talk about IT!

I am a member of  GLAM™ (Great Life After Menopause), a women’s health initiative sponsored by Novo Nordisk.

For more information: VaginalDiscomfort.com

Vaginal Atrophy by Staness Jonekos, MenopauseMakeover.com

1 The North American Menopause Society. The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Menopause. 2007; 14(3): 357–369.

2 Simon, J.A., et al. The Partners’ Survey: Impact of vaginal discomfort and its treatment – Insights, views and attitudes of postmenopausal women and their partners. North American Menopause Society (NAMS) Annual Meeting, October 2012. Abstract #1400532.

3 American Congress of Obstetricians and Gynecologists (ACOG). Women’s health: Stats & facts. 2011.

4 Hill K. The demography of menopause. Maturitas. 1996;23(2):113-127.

Press Release, here.

Novo Nordisk Launches GLAM™ (Great Life After Menopause) to Ignite the Conversation on Vaginal Health

GLAM™ (Great Life After Menopause)

A respected colleague, David Katz MD, MPH, Director Yale Prevention Research Center, with founder of the Yale Menopause Program, Dr. Philip Sarrel, just released the results of their latest study on hormone therapy.

Could estrogen have saved lives?

Dr. Katz wrote an insightful article starting that nearly 50,000 women may have died prematurely after they stopped taking hormone therapy to treat menopause symptoms following the much-publicized 2002 study that revealed the treatment increased the risk of heart disease and breast cancer.

This study validates what many experts and organizations, including The Menopause Makeover co-author Dr. Wendy Klein, have been saying for years … that hormone therapy is an acceptable option for the relatively young (up to age 59 or within 10 years of menopause) and healthy women who are bothered by moderate to severe menopausal symptoms.  Individualization is key in the decision to use hormone therapy.  Consideration should be given to the woman’s quality of life as well as her personal risk factors such as age, time since menopause, and her risk of blood clots, heart disease, stroke and breast cancer.

Lethal Placebo

By David L. Katz, MD, MPH

Everyone seems to love a riveting conspiracy theory- except, of course, the victims of it. We enjoy the gathering momentum of our collective outrage, and casting our passionate aspersions at some malefactor in the military industrial complex. In my world, that malefactor is often Big Pharma. Everyone loves to hate the harms that drugs do and the profits they generate along the way. Denigrating Big Pharma is a cultural pastime, and rollicking good fun.

And in the larger context of health care, it even makes sense. The prime directive of medicine, after all, is primum non nocere. Medicine becomes a legitimate target for scorn when it is a purveyor of net harm.

But what truly matters here is not the means, but the ends- the harm itself. What matters is life lost from years, and in the more extreme cases, years lost from life. And I have just such a tale to tell, but the means are peculiar. It’s not the drug that’s killing people- it’s the placebo.

My Yale colleague, Dr. Phil Sarrel, has devoted his career in large measure to a detailed knowledge of the overall health effects, and in particular the vascular effects, of ovarian hormones. Ovarian hormones- estrogen and its metabolites, and progesterone – profoundly influence a woman’s health from menarche to menopause, and then influence a woman’s health some more by disappearing.

Dr. Sarrel was in the vanguard of those who saw serious problems with the large, randomized clinical trials, published just at the turn of the millennium, that refuted our prior faith in the disease-preventing potential of hormone replacement therapy. The HERS trial, and the massive and massively influential Women’s Health Initiative (WHI), purportedly showed that we had been wrong about the advantages of hormone replacement, and that the practice resulted in net harm.

Even I was among those who noticed right away that the net harm was very, very slight- and grossly exaggerated in media headlines. But Dr. Sarrel was among those with the expertise to induce bigger worries.

Both trials had used the exact same form of hormone replacement, so-called “Prempro,” a combination of Premarin and medroxy-progesterone acetate. Premarin is estrogen derived from the urine of pregnant horses, and thus not native to humans. Medroxy-progesterone acetate is a synthetic progesterone, not native to any species, and many times more potent than human progesterone. Most experts, including my colleague, had long preferred other forms of hormone replacement, considering Prem/Pro a dubious choice.

But when HERS and the WHI tarred the practice of hormone replacement, it was with a broad brush. The news was not that Prem/Pro, one questionable approach to hormone replacement, resulted in benefits for some women and harms for others, with a very slight net harm at the population level. The news was: hormone replacement therapy harms women!

We already had potentially serious problems at this point, but the plot thickens considerably. Dr. Sarrel was also among those to note that these clinical trials administered Prem/Pro to women a decade after menopause. They did this to be sure the women were not just merely, but most sincerely post-menopausal. But we had cause to suspect then, and abundant reason to know now, that the benefits of ovarian hormone replacement accrue right at the time of menopause, and in the decade that follows. Timing is often crucial in medicine, as in life. Administer, for instance, a potent diuretic while a patient is fluid overloaded, and it can be lifesaving. Give just the same drug after they have already eliminated that excess fluid, and the result is apt to be hypotension and even death. Timing matters- and the hormone replacement trials got it seriously wrong.

All of this suggests that many women who might have benefited from good hormone replacement administered with good timing have missed out on those benefits because of the headlines engendered by HERS and the WHI. But the story does not end here, either. It ends, as noted, with a lethal placebo.

Quite a few months ago, Dr. Sarrel and I had the first of our recent intense flurry of meetings at my lab. He had brought me a paper published in JAMA in 2011, reporting on one particular subgroup included in the WHI: women who had undergone hysterectomy. The only reason to include progesterone in hormone replacement is to protect the uterine lining from overgrowth, so women who have had a hysterectomy are prescribed (or were, back in the days when hormone replacement was not the bogeyman) estrogen only.

Dr. Sarrel’s read of this paper was that the younger women- those age 50 to 59 and therefore just on the far side of menopause- had a considerably higher mortality rate when given placebo, rather than when given estrogen. I am formally trained in biostatistics and epidemiology, so my colleague asked me to verify this impression, which I did. Our project, and the resulting publication of our paper yesterday in the American Journal of Public Health, grew from there.

Working with a team from my lab, we devised a very simple formula to translate the excess death rate seen in the estrogen-only arm of the WHI to the entire population of such women in the United States: women in their 50’s, who had undergone hysterectomy. Hysterectomy is very common, arguably too common, so this population numbers in the many millions. We then needed to add into the formula the most reliable estimates we could find for the precipitous drop in estrogen prescriptions following the publication of the original WHI results back in 2002.

We, of course, had to run the details of our analysis through the gauntlet of peer review. And our paper now stands, in a highly esteemed journal, on full display before a jury of peers. So I can spare you the details of our methods, and focus on the punch line.

We estimated that over the past decade, due to a wholesale abandonment of all forms of hormone replacement for all categories of women by both the women themselves and their doctors, minimally 20,000, and quite possibly more than 90,000 women have died prematurely. We were very careful to incorporate only reliably conservative figures into our formula, so the numbers might actually be higher still. Being extremely cautious, we report that over 40,000 women have died over the past ten years for failure to take estrogen.

This death toll of estrogen avoidance, or better still, estrogen ‘aversion,’ represented some 4,000 women every year. Whatever the emotional impact of that figure, it should be greater- because any one of those women could be your spouse, or mother, or sister, or daughter, or friend. And the impact should be greater because the massively over-simplified, over-generalized, distorted “hormone replacement is bad” message continues to reverberate, and rates of all kinds of hormone replacement use continue to decline.

Stated bluntly, we think the mortality toll of estrogen avoidance is not merely a clear, present, and on-going danger, it is a worsening one. More women are dying from this omission every year. And the next one in that calamitous line could be a woman you love; it could be you.

I write this column, as my colleagues and I wrote our paper: with a sense of urgency, and even desperation. My career is entirely devoted to the prevention of avoidable harms, and the protection of years of life, and life in years. This is as clear-cut a case of preventable harms, and as readily fixable, as we are ever likely to see.

Here, then, are the take-away messages:

1) All forms of hormone replacement for all women at menopause was never right, but nor is NO forms of hormone replacement for NO women at menopause. There was always baby and bathwater here, and we have egregiously failed to distinguish between the two.

2) The millions of women who have undergone hysterectomy are candidates for estrogen-only hormone replacement at menopause, and when that treatment is provided at the time of menopause and for the years that immediately follow, it can both alleviate symptoms AND save lives. It could save the lives of thousands of women every year in the U.S., and no doubt many thousands more around the world where the tendency toward hormone replacement aversion also prevails.

Every woman who has had a hysterectomy should be open to the option of estrogen therapy at menopause, and should discuss it with her doctor. Every health care professional needs to know that some forms of hormone replacement for some women at menopause remain potentially life saving, and needs to address the topic accordingly.

3) Medical news is often translated into provocative headlines that abandon the nuances of the actual findings for the sake of maximal impact. This certainly happened when we learned that one form of hormone replacement resulted in a very slight excess of total net harm for one particular group of women, but is a far more systemic problem; it happens all the time. All of us plying our wares where medicine and the media come together need a bracing reality check: there are lives at stake! When headlines distort the actual state of medical knowledge and take on a life of their own, they can affect patient behavior and clinical practice-and the result can be the very harm medicine is pledged to avoid. I call upon my colleagues involved in the reporting of medical news to embrace the great responsibility that comes with the great power of the press, and to deliver their headlines accordingly. How many avoidable deaths is a maximally titillating, but misleading, headline really worth?

We’ve all seen the commercials on television; drug companies are required to report the various potential harms of their products, as they should be. But no one is required to report the potential harms of placebo. For the past decade, millions of women who might have enjoyed more life in years, and tens of thousands who might have enjoyed more years of life by taking estrogen, were, in essence, taking a “placebo” instead. And in this case, it was the placebo causing the harm. In this case, the placebo was- and all too often remains- lethal.

-fin

Dr. David L. Katz; http://www.davidkatzmd.com/

www.turnthetidefoundation.org

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