Vaginal dryness: a common women’s health issue

Case scenario

Mrs Jones has come into your pharmacy with a prescription for Vagifem Low pessaries (10 microgram estradiol). You ask Mrs Jones to join you in the private counselling area so you can discuss her condition and gather further information. Mrs Jones explains that she is going through menopause and visited her GP to get something to treat her persistent vaginal dryness. She has been fortunate so far to experience very few hot flushes, however she is finding the vaginal dryness particularly bothersome as she is experiencing intense itch and irritation. Sexual intercourse with her husband is painful. She is very keen for symptomatic relief but is concerned about using hormone therapy, as her mother died of breast cancer. Her girlfriend recommended she try the natural progestogen cream that she uses.

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Introduction

Vaginal dryness is a common and bothersome problem experienced by a large number of women at some point in their lives.¹ It occurs due to reduced vaginal secretions caused by decreasing estrogen levels.^2,3 It is most commonly experienced by women going through menopause but can also be experienced by premenopausal women. 

Vaginal dryness is one of the symptoms of the genitourinary syndrome of menopause (GSM).^2,4 GSM was previously known as atrophic vaginitis or vulvovaginal atrophy.⁵ Vaginal dryness may be accompanied by vulval GSM symptoms such as itching, burning, irritation or soreness in or around the vagina.^2,6 These symptoms can cause dyspareunia (painful intercourse),^2,6,7 and may lead to sexual dysfunction, such as hypoactive sexual desire disorder (HSDD),^1,8 with the associated personal distress impacting on relationships and mental health.^1,3,7 

Vaginal dryness can be treated effectively with low-dose vaginal estrogen.^7,9 Systemic estrogen-replacement therapy and tibolone may also reduce symptoms of GSM (including vaginal dryness) in women who are taking them for vasomotor menopausal symptoms.^2,10 

Publication of the findings of the Women’s Health Initiative (WHI)^11,12 in 2002 led to concerns about the safety of systemic hormone therapies and resulted in a global decline in their use.^7,13 Consequently, intravaginal non-hormonal treatment options such as personal lubricants have been increasingly recommended as a management option.^2,14,15 

Since vaginal dryness is a sensitive issue and most commonly associated with postmenopause, younger women may be reluctant to report their symptoms.^1,7 Pharmacists can provide lifestyle advice to women of all ages to help them maintain vaginal health, and advise on appropriate medicine use where indicated. 

Causes

Vaginal dryness is predominantly caused by decreasing estrogen levels, as occurs during perimenopause. Other causes of vaginal dryness are listed in Box 1.

Box 1 – Causes of vaginal dryness in premenopausal women

References: Goncharenko et al,¹ NHS,¹⁴ Gandhi et al,¹⁶ Carati et al,¹⁷ van Nimwegen et al¹⁸

Prevalence

GSM symptoms manifest in approximately 15% of premenopausal women¹⁹ and 40–54% of postmenopausal women.^2,20–23 The prevalence of vaginal dryness, and the extent to which women are bothered by it, varies between countries. The Australian Study of Health and Relationships conducted in 2000–01 found that 24% of female participants aged between 16 and 59 years reported experiencing vaginal dryness.²⁴ These findings are very similar to those from a study conducted in 2001–02 of Australian women aged 40–80 years where 26% of participants reported experiencing vaginal dryness.²⁵ The Global Survey of Sexual Attitudes and Practices, published in 2009, reported that 13.8% of the 603 Australian women who participated (age range: 18–65) experienced vaginal dryness regularly, with 10.7% describing it as ‘very bothersome’ and 3.6% reporting it was often associated with pain during sexual intercourse.⁷ Age is a predictor of vaginal dryness, with a higher incidence in women over 50.^7,21,26 In the Australian Longitudinal Study of Health and Relationships, 60% of the 955 Australian female participants who experienced sexual difficulties (age range: 20–64) reported vaginal dryness as a persisting issue.²⁶ 

Pathophysiology

Female genitalia and the lower urinary tract share common estrogen receptor function.¹⁶ These urogenital tissue receptors require adequate endogenous estrogen to maintain normal physiology and tissue integrity.^27,28 Estrogen is a vasoactive hormone that increases blood flow.²⁹ Activated estrogen receptors, vaginal secretions and vaginal lubrication (caused by fluid transudation from blood vessels in the vaginal wall) all contribute to maintaining vaginal integrity.^19,28 Rugae also play an important role in vaginal integrity. Vaginal rugae are transverse epithelial ridges in the mucous membrane of the vagina which contribute to its resiliency and elasticity, as well as its ability to distend and return to its previous state.^30,31 The vaginal rugae also aid lubrication during sexual intercourse.¹⁶ In hypoestrogenism, vaginal tissue has reduced collagen, elastin and hyaluronic acid levels, a thinner epithelial layer, impaired smooth muscle function, and a loss of vascularity.^16,32 The vagina becomes thin, dry, non-elastic and non-rugated, and the lubricating and elasticity functions are lost, resulting in GSM symptoms.^16,31,32 In postmenopause (natural or surgical), reduced endogenous estrogen levels result from a decline in the number of estrogen receptors).¹⁹ In addition, estrone (a less potent form of estrogen) becomes the most abundant of the three forms of estrogen produced.¹⁹

Symptoms of vaginal dryness

Symptoms of vaginal dryness include^2,7,14:

• irritation, itching, burning, chafing or other discomfort
• dyspareunia
• light bleeding after sexual intercourse (due to increased fragility and loss
  of pliability of vaginal tissue).

Management of vaginal dryness

Management of GSM and vaginal dryness varies depending on the individual patient and severity of symptoms.¹⁶ Table 1 outlines the treatment options available.

Prescription medicines

Vaginal or systemic estrogen effectively restores vaginal tissue integrity and vasculature, improves vaginal secretions, lowers vaginal pH to restore vaginal microbiome, and may alleviate symptoms.^{2,16,13,19,28,35} An analysis of data collected as part of the WHI trial has found that postmenopausal women who use vaginal estrogen have the same risk of invasive breast cancer, stroke, blood clots, endometrial cancer and colorectal cancer as women who don’t use vaginal estrogen.³⁶

Non-prescription options

Tea-tree oil and pawpaw ointment are generally not recommended, as they may cause contact dermatitis.² Combination local anaesthetic/disinfectant products relieve itching and dryness, however the local anaesthetic may cause contact dermatitis of the vulva, so these are also generally not recommended.^2,28  

Lifestyle considerations

There are various lifestyle strategies that pharmacists can provide to patients experiencing vaginal dryness.^2,14 

These include:

• Avoid washing the vaginal area with perfumed soaps or washes. Instead, use non-perfumed, hypo-allergenic soap alternatives or simply wash with plain water.^2,16
• Avoid using feminine hygiene sprays or douches in or around vagina.^2,16
• Avoid scented pads, tampons and toilet paper.^2,16 
• Wear cotton underwear and change it every day. Consider not wearing underwear when possible (e.g. when going to bed).^2,16
• Avoid or minimise time spent wearing tight-fitting pantyhose/tights, active wear, jeans or trousers to reduce possible sweating.^2,16
• Limit the amount of time wearing damp or wet swimming costumes.^2,16
• Wash clothing with non-perfumed or hypo-allergenic washing detergents. 
• Avoid the use of fabric softeners, and consider second rinsing if symptoms persist.^2,16
• Avoid shaving or waxing the genital area, particularly if there is irritation.^2,16
• Use a vaginal lubricant or moisturiser for sexual activity.² Do not use products like petroleum jelly (Vaseline) inside the vagina as it can cause infection (bacterial vaginosis).³⁷ 
• Engage in more foreplay to increase arousal during sexual intercourse.¹⁶ 
• Regular sexual activity should be encouraged to maintain vaginal health (sexual activity helps maintain vaginal elasticity and pliability and stimulates lubrication).¹⁶ Seminal fluid contains sex steroids, prostaglandins and essential fatty acids which also serve to maintain vaginal tissue integrity.¹⁶

Table 1 – Treatment options for vaginal dryness

References: Australasian Menopause Society,² AMH,⁹ eTG,¹⁰ Worsley et al,¹³ Santoro et al,²⁸ eTG,³³ Replens³⁴

Knowledge to practice

Vaginal dryness occurs in both pre- and postmenopausal women.^4,7,24,25 Many younger women with vaginal dryness find it difficult to discuss their symptoms with healthcare professionals because of its association with menopause.¹ Pharmacists are able to identify women with vaginal dryness when they are purchasing non-prescription vaginal lubricants and moisturisers. Knowledge of the cause, as well as management options for vaginal dryness, enables pharmacists to provide appropriate, tailored advice. Since GSM (including symptoms such as vaginal dryness) is a chronic condition, lifelong management is required to prevent recurrence of symptoms¹⁶ and maintain quality of life. Pharmacists are able to provide patients with management options, as many of the treatments are available in pharmacies and do not require a prescription. Tailoring advice to patients will help them decide on the most suitable management option. 

An Australian study found that despite a high prevalence of moderate to severe menopausal symptoms in Australian women, use of prescription hormone medicines in participants was low (11.3%).¹³ Of those participants using hormone medicines, most used oral estrogen, despite the availability of potentially safer therapies.¹³ This study highlights the underuse of vaginal estrogen and presents an opportunity for pharmacists to increase patients’ awareness of the safety and efficacy of low-dose vaginal estrogen and non-hormonal treatments. Pharmacists should be aware that there are concerns around the use of custom compounded ‘bioidentical’ hormone therapy due to a lack of regulation.³⁸

Communication on such a personal topic requires empathy and sensitivity. Privacy and confidentiality concerns on the part of the patient are natural. Offering to provide advice in a private counselling area where the conversation cannot be overheard may provide reassurance and reduce barriers to effective communication. This aligns with the PSA Professional Practice Standards.

Helpful information and support for both pharmacists and patients can be obtained from the website of the Australasian Menopause Society (www.menopause.org.au). This website is also useful for premenopausal patients with symptoms of vaginal dryness – pharmacists should reassure this patient group that they too will be able to obtain relevant and helpful information on management options and lifestyle considerations for their condition. The Australian Pharmaceutical Formulary and Handbook has a non-prescription medicine guide titled Bacterial Vaginosis and Vaginal Thrush.⁶ This guide provides information on potential causes of different vaginal symptoms as well as signs and symptoms that require referral.⁶    

Conclusion

Pharmacists are able to assist patients experiencing vaginal dryness (and GSM) to make informed treatment decisions and optimise management of their symptoms. They also have the potential to improve the quality of life of a large number of patients by providing reassurance on the safety and efficacy of low-dose vaginal estrogen, as well as advising on non-hormonal therapies (including vaginal lubricants and moisturisers) and lifestyle strategies. 

Key points

• Vaginal dryness is associated with reduced estrogen levels and affects women of all ages.
• Vaginal dryness can be treated with vaginal estrogen (cream or pessary).
• Non-hormonal therapies for vaginal dryness, including vaginal lubricants and moisturisers, are available from pharmacies without a prescription.  
• Lifestyle strategies can be helpful to manage symptoms of vaginal dryness. 

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Dr JUDITH SINGLETON BPharm, PhD, MBA (Hons), GradCertAcadPrac is a Senior Lecturer in the School of Clinical Sciences (Pharmacy Discipline) at Queensland University of Technology with over 30 years’ experience as a pharmacist practising in community and hospital settings.

References

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