Dry, Itchy, Scratchy: What Is Happening

You Are Not Alone

It is estimated that 70-80% of women will experience genitourinary syndrome of menopause (GSM). The European REVIVE (Real Women’s Views of Treatment Options for Menopausal Vaginal Changes) 2016 study noted the following % of women reported:

• Vaginal dryness (70%)

• Significant impact on the ability to be intimate (62%)

• Enjoy sexual intercourse (72%) 

• Feel sexual spontaneity (66%)

• Sexually active (51%), but reduction in sexual drive is reduced

• Health-care professionals (HCPs) have discussed GSM (62%), but of these, physicians initiated the conversation only in 10% of the time 

• The most common treatments for GSM were over-the-counter, non-hormonal, local vaginal products. This is despite the strongest evidence for treatment being vaginal estrogen or DHEA.

• 32% naïve to any kind of treatment

What is clear is GSM is  under-diagnosed and under-treated, with a high rate of dissatisfaction for  actual  available treatments and fear of hormone therapy and misinformation being a driver for not adopting the gold star treatment. Moreover, GSM does not improve over time and is likely to progress making treatment of even more importance. 

Take the vulva, vagina, and urinary tract health quiz! 

Treatment: Medications & Supplements

Hormonal Medications

The most common treatments for vaginal changes during menopause (called genitourinary syndrome or GSM) are over-the-counter, non-hormonal, local vaginal products, this is despite evidence that the gold standard for treatment is local vaginal estrogen (estradiol) with some clinical trials demonstrating 80 to 90% effectiveness.

Vaginal estrogen is a localized treatment that replenishes estrogen in the genitourinary area. It comes in the form of suppository, creams, or a 3-month vaginal ring, which can be inserted directly into the vagina or applied to the labia. Applied topically, prescription estrogen can amp up the lubrication and elasticity of vaginal walls.

If your perimenopause symptoms expand outside of GSM and libido, for example night sweats, brain fog, weight gain, and joint soreness, a doctor might recommend a systemic approach. This would be hormone replacement therapy (HRT), a dose of estrogen and progesterone. However, HRT alone is not as effective as local estrogen for GSM symptoms because there is not a sufficient amount of estrogen reaching the vaginal and vulvar tissues. If you have already started with HRT however, you might wait to see if it is effective for your GSM symptoms before adding the cream.

DHEA is a hormone involved in the process of converting cholesterol to estradiol (a type of estrogen). It is a newer hormone to be prescribed by physicians for GSM and is taken as a one dose suppository. DHEA (also known as Prasterone or Intarosa) increases blood estrogen concentration leading to improvement in sexual arousal and return of libido. It is inserted into the vagina nightly and has been shown to be effective in improving sexual function.

Testosterone, the traditional ‘male sex hormone’ is actually extremely important for women and our overall health. While no surprise, there is a paucity of longitudinal research on testosterone for women and no approved dose however, some physicians do prescribe testosterone off label or compounded in particular to support sexual desire concerns.

Non-hormonal Medications

Ospemifene (Osphena) is a non-estrogen medicine that reverses certain changes in vaginal tissue that are caused by menopause. It can indirectly impact sexual desire by providing relief of moderate to severe vaginal dryness and pain during sex. Ospemifene is a selective estrogen receptor modulator (SERM) which means it acts like an estrogen on some tissues and like an anti-estrogen on others.

Anti-depressants called SSRIs have been found to have some impact on libido for women in menopause. In particular, Wellbutrin (Bupropion) which increases blood flow to the vagina, vulva, clitoris has been shown to be effective for women suffering from a lack of sexual desire. There are potential serious side effects, however, including suicidal thoughts.

Addyi (Flibanserin) is a serotonin agonist antagonist (MSAA) which works to correct an imbalance of the brain chemicals called neurotransmitters, specifically dopamine and norepinephrine (both responsible for sexual excitement), while decreasing levels of serotonin which can lower your sex drive. Addyi is taken to deal specifically with female sexual desire, effect sizes do not appear large, and the drug is taken daily, has some uncomfortable side effects, and interacts negatively with alcohol so you cannot consume alcohol while taking Addyi.

Vyleesi (Bremelanotide) also works to balance neurotransmitters in the brain. Vyleesi focuses on the neurotransmitters called melanocortin receptors. The exact way that Vyleesi improves sexual desire is still not fully understood. However, in one study, 25 percent of women reported an increased sexual desire score, compared to 17 percent of those who received a placebo. It is injected 45 minutes prior to sex. Alcohol can be consumed while taking the drug.

Scream cream is a topical preparation determined by a physician’s prescription of ingredients and doses. The recipe depends on the pharmacy and is based on increasing blood flow to your pink parts. It often includes Sildeafil (generic Viagara) and is applied for a few seconds to the vaginal and clitoris areas about 30 minutes prior to sex to dilate nearby blood vessels and lasts approximately 2 hours. Without a standard formulation and limited research on the effectiveness, it is unknown if the act of self-stimulation of applying the cream might influence arousal and blood flow as effectively as scream cream itself.

Marijuana

While control trial research is required to validate the potential value of marijuana for sexual desire, survey research has found a positive impact on self-reported sexual desire for women using the drug.

Supplements & Herbs

As an unregulated space, the supplement and herb industry presents some challenges. In particular, the type, consistency and amount of ingredients one company uses can vary substantially. In addition, it is an area with few random control trials to really evaluate effectiveness. That does not mean it might not be a viable option for you, you just need to be informed and observant of real effects versus placebo.

Vitamin D. Research supports an improvement in sexual desire for both women deficient and with sufficient Vitamin D. Other sexual function benefits such as enhanced orgasm and an overall reduction in sexual dysfunction among women with low Vitamin D levels was also noted. While more research is required initial findings are positive for Vitamin D and sexual desire, moreover, given the importance of Vitamin D  for your overall health, it is valuable to ensure your Vitamin D levels are in a healthy range.

Vaginal Vitamin E. A systematic review of studies on vaginal Vitamin E concluded that more research is required to determine if Vitamin E has a positive impact on GSM and in this case sexual desire.

Korean Red Ginseng. Red Ginseng has been shown in random control trials to improve sexual desire among menopausal women. The doses of ginseng used in the studies ranged from 200 to 3000mg per day, and the treatment periods from 2 to 16 weeks.

Phytoestrogens. Phytoestrogens are plants that have similar structures to endogen estradiol and may be able to bind with certain estrogen receptors. In simple terms, eating ‘estrogen’ like plants to increase your estrogen. There are many different types of phytoestrogens. While research is limited, phytoestrogens have been noted to have variable effects on sexual function. Published reports show that maritime pine bark, T. foenum-graecum L., and F. vulgare may support sexual desire while soy, red clover, genistein, and flaxseed had no real impact.

Ashwagandha. 300mg twice a day of this adaptogenic root for 8 weeks may help reduce GSM symptoms and has been linked to increased libido. One pilot study of 50 subjects noted significant improvements in arousal, lubrication, orgasm and sexual satisfaction .

Treatment: Platelet-Rich Plasma (PRP) Injections

PRP treatment involves extracting a small amount of blood from your body. The blood is spun in a centrifuge and then plasma responsible for growth and repair is injected into the area where restoration is desired. In this case, the vestibule and vaginal wall. While more random control trials are needed, the initial evidence is showing positive effects on GSM including sexual health. 

Treatment: Let’s Get Physical

Exercise increases blood flow to the vagina and serves to reduce stress and anxiety (common libido killers). Research shows a relationship between physical activity and libido, including among older adults. This should come as no surprise given the plethora of data showing exercise supports hormone balance, including testosterone through resistance training, improved body image and self-confidence, increased energy and stamina, and improved mental well-being and sleep. All of these also support a vibrant libido.

In addition, being proactive with your pelvic floor fitness is a great preventive mechanism to support a healthy vagina. Pelvic floor exercises, commonly known as Kegel exercises, involve contracting and relaxing the muscles of the pelvic floor. These exercises can improve muscle tone and strength in the pelvic region, increase vaginal lubrication and blood flow to the area, supporting sexual pleasure and both the ease and intensity of orgasm. For more information on Kegel exercise, check out the PAUZ Resources.

Technology: Energy Based Therapies

Laser or radio frequency devices heat the vaginal tissues causing an increase in blood flow and promotion of tissue remodeling and collagen which can build elasticity. This is a newer space with more research required to validate (23). While random control trials have shown no harm, it is not currently recommended by the North American Menopause Society, this is likely given earlier technology that poised risks of burning the vaginal tissue. If you are electing to try this, ensure you are going to a location with an obstetrician-gynecologist expert.

Radiofrequency treatments, like the EmFemme 360 for example heat the vaginal walls and ultrasound which does not go inside the vagina such as Madorra. There are many companies providing this, effects are dependent on many factors such as laxity of the vagina. 

There are at-home tools on the market such as Joylux vFit Gold (started at $169 USD). vFit is a red-light wand that’s inserted into the vagina for 6- to 10-minute sessions, 3 times per week. Results are stated to occur after 6 to 8 weeks of consistent use. 

While it is still taboo for women to discuss anything related to sex including our desire to have it, any changes in our vagina, mind, or body impacting libido, it is time to change that and take life by the ovaries! Be part of the movement empowering women to go after the sex they deserve.

Resources:

Angelou K, Grigoriadis T, Diakosavvas M, Zacharakis D, Athanasiou S. The Genitourinary Syndrome of Menopause: An Overview of the Recent Data. Cureus. 2020 Apr 8;12(4):e7586. doi: 10.7759/cureus.7586. PMID: 32399320; PMCID: PMC7212735.

Amabebe E, Anumba DOC. The Vaginal Microenvironment: The Physiologic Role of Lactobacilli. Front Med (Lausanne). 2018 Jun 13;5:181. doi: 10.3389/fmed.2018.00181. PMID: 29951482; PMCID: PMC6008313.

Lev-Sagie A. Vulvar and Vaginal Atrophy: Physiology, Clinical Presentation, and Treatment Considerations. Clin Obstet Gynecol. 2015 Sep;58(3):476-91. doi: 10.1097/GRF.0000000000000126. PMID: 26125962.

Davis S.R, Pinkerton J, et al. Menopause-Biology, Consequences, Supportive Care and Therapeutic Options. Cell. 2020 Sept;186(19): 4038-58. doi: DOI:https://doi.org/10.1016/j.cell.2023.08.016 DOI

Nappi RE, Palacios S, Particco M, Panay N. The REVIVE (REal Women's VIews of Treatment Options for Menopausal Vaginal ChangEs) survey in Europe: Country-specific comparisons of postmenopausal women's perceptions, experiences and needs. Maturitas. 2016 Sep;91:81-90. doi: 10.1016/j.maturitas.2016.06.010. Epub 2016 Jun 15. PMID: 27451325.