This is Part 3 of our 3-part series on Menopause. ICYMI - be sure to catch up on parts 1 and 2 (links below) where Dr. Kimberly Langdon covered UTIs and VVA and how they are linked to Menopause. And now, Part 3:
Even though menopause brings on many changes for women, most of them are manageable. One problem, however, is often ignored until it becomes advanced. It is called vaginal atrophy or vulvovaginal atrophy (VVA). It is also known as genitourinary syndrome of menopause (GSM) because the lining of the bladder can be affected as well. Thinning walls, fewer blood vessels, less lubrication, and shrinkage of the vagina are the result of VVA. Once advanced, painful sex is often the result. Dyspareunia is the medical term for painful sex and is defined as recurrent or persistent pain with sexual activity that causes marked distress.
While many conditions can cause dyspareunia, lack of estrogen in menopause is the primary culprit. Pain during sex can begin with initial penetration, with thrusting, or a combination of the two. Pain during sex can be a result of anatomic variety such as size, shape, the orientation of reproductive organs, nerves, and muscle development. Hormonal changes, underlying infections or diseases, and emotional factors can all impact a woman's ability to have and enjoy sexual intercourse.
The length of a woman's vagina and the direction that the uterus is tipped (forward or backward) can be one reason for pain during sex. Shorter vaginas and a uterus that is tilted towards the rectum are more common anatomic factors that can cause pain. This usually shows up in the earlier reproductive years long before menopause. Women who have pelvic organ prolapse such as a dropped bladder or uterus (which is uncommon unless the woman has had multiple pregnancies) can cause both initial and internal pain during sex. During menopause, this prolapse can worsen due to the aging process, gravity, weakened ligaments, and other supporting structures.
Diseases or Conditions That Can Cause Pain During Sex
There are diseases of the female reproductive tract that can cause pain such as:
- Pelvic inflammatory disease (PID) - an STD that scars fallopian tubes
- Ovarian cysts- benign growths on the ovaries
- Endometriosis - lining of the uterus that spreads to other areas
- Adenomyosis - lining of the uterus that buries into the muscle of the uterus
- Skin rashes of the vulva- lichen sclerosis and others
- Bladder diseases - Interstitial cystitis
- Autoimmune diseases - Sjogren's Syndrome
- Gastrointestinal conditions - Inflammatory bowel conditions
- Childbirth lacerations
- Diabetes- frequent yeast vaginitis
Besides vaginal dilators (to widen and lengthen the vagina) and lubrication, topical steroids and oral medications can be useful for women with pain during sex. Estrogen therapy during the menopausal years, both orally and topically, can improve the vaginal collagen and blood supply, which is crucial for the production of natural lubrication and elasticity. A recent FDA approval of a c (DHEA) treatment goes by the brand name of Intrarosa and is beneficial for those who cannot take estrogens due to cancer or a history of blood clots. Sometimes, anti-anxiety and anti-depressant medications are used to reduce pain, muscle spasms and fear of penetration.
For women who choose not to take oral or topical estrogens, there are natural supplements like Femina that help boost estrogen naturally from various plant sources. Femina contains black cohash, soy, dong quai, licorice, sage, wild yam, chasteberry, and other ingredients that have mild estrogenic properties. Treatment should continue for at least 3-4 months to see the full effect. Once you experience improvement, daily use is recommended.
The thing about sex, according to gynecologists, is, “If you don't use it, you lose it,” meaning that the more sex you have, the healthier your vagina remains, free of pain and other problems.
In Case You Missed it
Part 2 - VVA? Do you know what it is?
Lethaby A, Ayeleke RO, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2016 Aug 31;2016(8):CD001500. doi: 10.1002/14651858.CD001500.pub3. PMID: 27577677; PMCID: PMC7076628.