It’s so painful, we just stopped having sex.

I hate hearing this from patients. If someone said, I’ve decided not to have sex anymore because - pick any random thing that isn’t a treatable, reversible medical condition - ok, cool. You do you. It’s not my job to care. However, when someone says this and I know there are things we can do to make it better, it makes me really sad. When someone says this and they’ve been told a lie - like using low dose vaginal estrogen might cause breast cancer, I get angry.

So, today, we will delve into peri/post menopausal painful sex. Younger ladies, I hear you and will turn around and write a post for you. The causes are different and therefore the treatments are also different. So, if you’ve gotten your first grey hair and you have painful intercourse, this blog is for you.

So, we have a few topics to hit - vaginal atrophy, vaginismus, interstitial cystitis and pelvic orgam prolapse. I then have a bonus section for the it’s been 5 years and now I have a new partner I’d like to be intimate with.

Vaginal atrophy - without estrogen - whether natural menopause, surgical menopause, or drug induced low estrogen (endometriosis and breast cancer treatments among others), the vagina changes shape and texture. Vaginal skin that is estrogenized is stretchy, has alot of vascularity, so it lubricates well (the fluid being a transudate that has to move from vessels across tissue to the surface of the vagina) and overall has a healthy pink appearance. When estrogen is not present, the skin doesn’t stretch - it tears, doesn’t have vacularity - so it doesn’t lubriate and without the blood flow looks more white instead of pink. The result is that the vagina becomes narrower, more constricted and unable to accomodate the erect penis easily (even with a lubricant because of the inability to stretch) and dryer.

The treatment: put estrogen back. There is almost no one who is not a candidate for vaginal estrogen. Undiagnosed postmenopausal bleeding and active uterine cancer are about the only exceptions. Topical low dose vaginal estrogen isn’t absorbed systemically - as proven by looking at blood estradiol levels in women taking it - and this means we know that it can’t possibly cause stroke, heart attack and breast cancer as the label USED TO say. Ok, it may say it for a few more months, but they are rewriting it now. Vaginal estrogen has suffered from unnecessary reputational damange due to the class warning applied to all estrogens with no evidence that it caused these things when used topically. It’s only taken 20+ years for the FDA to correct this error in judgement, but yea for progress. Of note, clinical trials and database reviews have been done showing no increase in breast cancer recurrence for women using topical vaginal estrogen for management of vaginal estrogen.

Other options: we hit the easiest and cheapest above. There are a few alternatives though. Vaginal DHEA cream - there was a thought that if you put the precursor to estrogen - DHEA on the vaginal tissues, maybe it would be converted to estrogen locally in the tissues. I’ve had some patient’s for whom this has been beneficial and some that said it did nothing. The commercial version has always been ridiculously expensive - the FDA limiting competition with the class label really stomped all over the free market - and I just think you might was well use the estradiol cream that has fantastic results and lots of safety data. We can also use vaginal moisturizers with things like hyaluronic acid and I have had patient’s who had success, but again, it’s just not as good as estradiol. Vaginal rejuvenation via laser - yes it works, but it is very expensive. If it’s worth it to you, it’s three treatments - once a month x 3 months and then you usually need a yearly touchup. Prices range from $1500-$5000. Most of my patient’s who have chose this have liked it and felt like they got their money’s worth. The important thing to note is that as time marches on, you will have to repeat the laser treatments. the Annual follow up is usually $500-1000.

The O-shot. Not going to lie, when I heard about this, I thought it was made up. I think this procedure was mainly developed in the aesthetic space and because of that, it of course has a fun name. What is it? Injection of platelet rich plasma (PRP) around the clitoris and in the vaginal walls. I actually heard about this from patients - meaning the marketing is going well - but couldn’t find any evidence. Today I can say that I have now seen some actual evidence published in quality journals. In fact, the number one journal in our field just had an article on it. I also did a quick lit search before writing this and have found several randomized controlled trials (often considered the highest form of evidence) and while they are small, all are trending in the direction of real improvement. What I have found are two different versions - the injections just around the clitoris, which help with orgasm and the injections into the vaginal walls mostly intended to help with vaginal atrophy. Both have good data and both offer alot of promise. As with all things, I would expect to need follow up. Most studies use a model of 3 or 4 monthly injections, but some use only 1 or 2. Data looks really good at 6 months, but I suspect that by 12 months, additional therapy or maintenance with something like vaginal estrogen will be necessary. I’m excited to bring this new option into the clinic because it’s essentially drug and laser free. It just uses the plasma from your own blood. It makes sence because the main reason people use PRP (the oral surgeons were first and did the real bench research in the field and then the dermatologists caught on) is because the stimulation from the platelet derived growth factors stimulates the production of collagen and growth factors. This is how estrogen and lasers works promotion of collagen production and increased vascularity from growth factors.

Vaginismus - when beign touched with a q-tip is interpreted as being touched by razor blades. This is most common in postmenpausal women and women who are victims of sexual trauma. For the postmenopausal women, vaginal estrogen is helpful, but often can’t resolve symptoms entirely. We fall back on pain modulators and neuropathic pain drugs like amitriptyline and gabapentin to help these ladies. We also can use topical numbing agents for things like sexual intercourse. Occasionally, surgical recisio of the area called the vestibule is a measure of last resort. Personally, in all my patient’s that have this, it isn’t confined to the vestibule in any of them, so I have doubts about the usefulness. Fow women who have been victims of trauma, pyschotherapy and pelvic floor physical therapy are immensely helpful, but we have to overcome in order to get the physical body back on track.

Interstitial cystitis is an autoimmune condition where you feel like you have a UTI all the time. Most women have at least a half a dozen negative urine cultures before we make the diagnosis. Blood in the urine is often the only diagnostic positive. Confirmation requires either putting some caustic stuff in the bladder and seeing if the patient kicks you in the face or doing a cystosocpy to look for ulcerations in the bladder mucosa. As I don’t fancy getting kicked in the face and often don’t feel the expense of cystosocpy is warranted, this is generally a diagnosis of exclusion for me - rule out infection, look at history, and then go for treatment. Similar to vaginismus, pain modulators and neuropathic agents help. Applying topic meds to the bladder is more difficult, but can be done and is called a bladder instillation. We usually do this weekly x 4 and then monthly x 4 to help rebuild the bladder’s protective layer - called the GAG layer. IC tends to flare and relapse and flare and relapse. Managing the flares is key.

Pelvic organ prolapse - as stuff falls out, it can tend to get in the way. For some people, this is no big deal, but if it is, generally surgery is the way to go. Pessaries and sewing the vagina shut don’t work well if the goal is good sex.

Ok, the bonus for when you haven’t had sex for years and you are ready to get back in the game. For postmenopausal women, the vagina is something that goes by the saying “if you don’t use it, you loose it.” In other words, the act of having sex makes it easier to have sex. If you haven’t been sexually active, you may find that there has been a decrease in the length and caliber of the vagina. We are talking severe atrophy here. So, what do we do? If you had vaginal estrogen on your bingo card, you have been carefully studying this article. Estrogen is key, but won’t be enough in the long term. We need collagen development. If you just put the estrogen there, but never apply any stretch to the tissue, you won’t get good collagen development. What I recommend is starting the vaginal estrogen, which will take about 12 weeks to be fully effective, but after the first 6 weeks of estrogen therapy, I have patient’s start working with vaginal dilators. To use these, you insert the smallest dilator first and work up to the first one you cannot easily insert. you gradually put pressure until this dilator can be fully inserted. leave it for 5-10 minutes and then remove and you are done. Gradually, you should be able to work up to the largest dilator. Generally, by the time we get to 12 weeks, we can get up to the largest dilator.

If you are having problems with painful intercourse, don’t ever be embarassed to talk about it with your healthcare provider. There are things we can do to make it better.