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OVERVIEW — Vaginal dryness is a common condition in postmenopausal females (ie, people who have been through menopause). This condition is also common in people who have had both of their ovaries surgically removed, for example, to treat or prevent cancer. You may hear your health care provider use the term "atrophic vaginitis" or "genitourinary syndrome of menopause."
Vaginal dryness may not be bothersome, but in some cases it can lead to uncomfortable symptoms, such as pain with sex, burning vaginal discomfort or itching, or abnormal vaginal discharge. There may also be related urinary symptoms, such as frequent or painful urination. These symptoms may lead to less satisfying sex and avoidance of sexual intimacy.
Fortunately, there are several effective treatments available. If you have symptoms of vaginal dryness, talk to your health care provider about which treatment is right for you.
CAUSES — The hormone estrogen helps to keep the vagina moist, maintain thickness of the vaginal lining, and keep the tissue flexible (also called "elasticity"). Vaginal dryness occurs when your body does not produce enough estrogen. This can be permanent or temporary and can occur at different times throughout life, such as:
●At the time of menopause (one year after monthly periods stop). (See "Patient education: Menopause (Beyond the Basics)".)
●After surgical removal of the ovaries, chemotherapy, or radiation therapy of the pelvis to treat cancer.
●After having a baby in those who are breastfeeding – Estrogen production returns to normal when breastfeeding becomes less frequent or is stopped.
●While using certain medications, such as danazol, medroxyprogesterone (brand names: Provera, Depo-Provera), leuprolide (brand name: Lupron), or nafarelin – When these medications are stopped, estrogen production usually returns to normal.
TREATMENT — There are several treatment options for vaginal dryness. Some, such as vaginal moisturizers or lubricants, are available without a prescription. Others require a prescription; these include a vaginal estrogen cream, tablet, capsule, or ring; an oral medication called ospemifene; and a vaginal tablet called prasterone. These treatments are usually used continuously with monitoring, as they only work temporarily; your symptoms will return when the treatment is stopped unless your ovaries start producing more estrogen again.
Vaginal lubricants and moisturizers — You can buy these without a prescription in most pharmacies. Vaginal lubricants and moisturizers do not contain any hormones and have virtually no systemic (body-wide) side effects. Possible local side effects include irritation or a burning feeling after application.
●Lubricants are designed to reduce friction and discomfort from dryness during sexual intercourse. The lubricant is applied inside the vagina and/or on the partner's penis or fingers just before sex. Products sold specifically as vaginal lubricants are more effective than lubricants that are not designed for this purpose, such as petroleum jelly. In addition, oil-based lubricants like petroleum jelly, baby oil, or mineral oil can damage latex condoms and/or diaphragms and make them less effective in preventing pregnancy or sexually transmitted infections. Lubricants that are made with water or silicones can be used with latex condoms and diaphragms. Polyurethane condoms can be used with oil-based products.
Natural lubricants, such as olive, coconut, avocado, or peanut oil, are easily available products that may be used as a lubricant with sex. However, it is important to know that, like the oil-based lubricants, natural oils are not recommended for use with latex condoms or diaphragms, as they can damage the latex. Water- or silicone-based lubricants are a better choice if you use condoms or a diaphragm.
●Vaginal moisturizers usually include hyaluronic acid and are formulated to allow the vaginal tissues to retain moisture more effectively. Moisturizers are applied into the vagina (as a gel or suppository) approximately three times weekly to allow a continuous moisturizing effect. Be sure to check the label to ensure that you are purchasing a moisturizer and not a lubricant.
Both lubricants and moisturizers are also available in preservative-free forms.
Hand and body lotions and moisturizers should not be used to relieve vaginal dryness since they can be irritating to the vaginal tissues.
Vaginal estrogen — Vaginal estrogen is one of the most effective treatment options for vaginal dryness. Vaginal estrogen requires a prescription from your health care provider, so ask about this if lubricants and moisturizers are not doing enough to relieve your symptoms. These therapies restore the topmost layer of vaginal cells and increase elasticity and connective tissue when used on a regular basis. (See 'Vaginal lubricants and moisturizers' above.)
Some people worry about possible side effects from hormones. Very low doses of estrogen can be used to treat vaginal dryness when it is in the form of a vaginal cream or insertable tablet, capsule, or ring. A small amount of estrogen is absorbed into the bloodstream with these vaginal forms, but when used regularly, the level of estrogen in the blood is in the same range as in postmenopausal females who are not using vaginal estrogen. As a result, there is a much lower risk of the side effects people sometimes worry about, such as blood clots, breast cancer, and heart attack, compared with other estrogen-containing products (eg, birth control pills, menopausal hormone therapy).
Several types of vaginal estrogen products are available:
●Cream – Estrogen cream is measured with an applicator and inserted into the vagina (if inserting the applicator is uncomfortable, you can also use your fingertip to apply and insert). The vaginal cream has the benefit of coating the vaginal tissues. The cream is usually inserted every day for two weeks and then twice weekly after that.
●Tablet or capsule – The vaginal estrogen insert is a small tablet or capsule that you put in your vagina. It comes packaged in a disposable applicator. It is usually inserted every day for two weeks and then twice weekly after that. Some people find it uncomfortable to insert the applicator at first, when vaginal dryness is at its worst; if you have this problem, ask your health care provider if you should use another form of vaginal estrogen.
●Ring – The vaginal estrogen ring (brand name: Estring) is a flexible plastic ring you wear inside your vagina all the time. You replace it with a new ring every three months. The ring does not need to be removed during sex or bathing. It cannot be felt by most people or their sexual partners. In people who have previously had a hysterectomy, the ring will sometimes fall out.
The estrogen ring used to treat vaginal dryness should not be confused with a different estrogen replacement vaginal ring (brand name: Femring), which releases a much higher dose of estrogen. The estrogen in the higher dose ring is intended to be absorbed into the body to relieve hot flashes in people going through menopause (See "Patient education: Menopausal hormone therapy (Beyond the Basics)".)
Do I need to also use a progestin medication? — With some vaginal estrogens, you may also need to a take another hormonal medication, called a progestin. This is to prevent the lining of your uterus from building up and becoming precancerous or cancerous. However, many people using low-dose vaginal estrogen will not need to use a progestin. Ask your health care provider whether you need to take a progestin with the vaginal estrogen you are using.
How long can I use vaginal estrogen? — As low-dose vaginal estrogen is associated with few adverse effects, it can probably be used indefinitely, although there are no long-term studies to provide data about the effects over many years.
Is vaginal estrogen safe if I have a history of breast cancer? — The safety of vaginal estrogen in people who have a past history of breast cancer is debated. A small amount of estrogen can be absorbed from the vagina into the bloodstream. Some people (those treated with a type of medication called "selective estrogen receptor modulators") may be better candidates for vaginal estrogen than others (those treated with a medication called an "aromatase inhibitor"). If you have a history of breast cancer, talk to your health care provider or oncologist about the potential risks and benefits of vaginal estrogen.
Prasterone (dehydroepiandrosterone) — Prasterone, also known as dehydroepiandrosterone (DHEA), turns into estrogen and testosterone in the vagina and is also an option for people with vaginal dryness due to menopause. It comes in the form of a suppository that you insert into your vagina once a day. Vaginal estrogen therapy is more commonly used than prasterone because vaginal estrogen has been studied more thoroughly and the dosing schedule may be more convenient. However, prasterone is an option for those who cannot take estrogen or prefer to avoid it, but who can use other vaginal hormones.
Ospemifene — Ospemifene is a prescription medication that is similar to estrogen but is not estrogen. In the vaginal tissue, it acts similarly to estrogen. It comes in a pill and is prescribed for people who want to use an estrogen-like medication for vaginal dryness but prefer not to use (or have trouble inserting) a vaginal medication. Ospemifene may cause mild hot flashes as a side effect; it may also increase the risk of blood clots or uterine cancer. Long-term studies of ospemifene are needed to evaluate the risk of these complications. This medication has not been tested in people who have had breast cancer or are at a high risk of developing breast cancer.
Other therapies — Other therapies, such as vaginal laser, other energy-based devices, or alternative topical medications (such as vitamins and probiotics) have been marketed as treatments for vaginal dryness. However, the safety and efficacy of these treatments remain uncertain.
SEXUAL ACTIVITY — Treatments may improve dryness quickly, usually within a few weeks. If sex is not uncomfortable, you can continue to have sex as you treat vaginal dryness. Intercourse may help the vaginal tissues by keeping them soft and elastic. If sex continues to be painful despite treatment for vaginal dryness, talk to your health care provider. You may have spasms in the vaginal muscles and there may be other things you can try.
WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Uterine cancer (The Basics)
Patient education: Sex problems in females (The Basics)
Patient education: Vaginal dryness (The Basics)
Patient education: Dyspareunia (painful sex) (The Basics)
Patient education: Sjögren's syndrome (The Basics)
Patient education: Vulvar pain (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Menopausal hormone therapy (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Desquamative inflammatory vaginitis
Clinical manifestations and diagnosis of menopause
Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis
Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment
Female sexual pain: Differential diagnosis
The following organizations also provide reliable health information [1-5]:
●National Library of Medicine
(www.nlm.nih.gov/medlineplus/ency/article/002142.htm)
●The Hormone Foundation
(www.hormone.org/questions-and-answers/2011/vaginal-atrophy, available in English and Spanish)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Richard J Santen, MD, who contributed to an earlier version of this topic review.
