vaginal issues in menopause: q&a with an ob/gyn (part 2)
In vaginal issues in menopause: q&a with an ob/gyn (part 1), we talked with Dr. Rebecca Dunsmoor-Su, OB/GYN and Director of Health at Gennev, about the possible causes of vaginal issues. She filled us in on what’s going on in a woman’s body during perimenopause and after, what to look out for, and how to have open and honest conversations with your doctor.
In part 2, Dr. Dunsmoor-Su tackles the solutions – hormonal, non-hormonal, laser, and alternative options – and how we can better prepare the next generation of doctors to help women have an easier, healthier transition.
Seven: How can doctors help – what solutions can doctors offer, medically, to help women with vaginal issues?
There are many things we can offer. I think about them in three categories: hormones, non-hormonal medications, and laser treatment.
Hormones and the laser treatment work by changing the tissues back to a pre-menopausal state. The non-hormonal medications work by alleviating symptoms, but they don’t change the tissues.
In terms of hormones, in my experience, treating the vagina directly is key to getting a good response. There are hormone creams, which have a higher dose of hormone, and then there are the ring or the tablets, which are much lower dose. Some women respond well to the lower dose, but it is definitely not as effective as the cream. There are different levels of systemic absorption of the hormone from the vagina, so you need to discuss this with your provider as it relates to your risks.
Additionally, if you use the vaginal creams and still have a uterus, you need to make sure you take progesterone in some form to prevent uterine cancer. The low dose tablets and ring are sometimes used in women with a history of breast cancer, but this requires a good conversation about risks versus benefits with your doctor.
Osphena is an oral medication called a selective estrogen receptor modulator, which has effect on some estrogen receptors and not others.
Intrarosa is DHEA which is a precursor hormone that your body turns into estrogen and testosterone. Both have limited data for benefit in vaginal symptoms (they have shown positive effects in small, limited studies). My concern with these medications is that we don’t have good long-term studies on risks and sustained benefit. I have seen some women get good effect from them. Nether is recommended for breast cancer patients or survivors.
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When I say this I am referring to vaginal moisturizers and lubricants. There are many on the market (including those from Gennev, which I think are some of the best). These are designed to relieve symptoms, but do not fundamentally change the tissues in any way. When choosing a moisturizer, make sure it is pH balanced and does not contain extraneous scents or ingredients.
I believe that all women in menopause should be using a lube, as adequate lubrication prevents pain. I recommend that women in midlife and menopause use a lube that is pH balanced, contains no scents or unneeded ingredients (herbs are not meant to be in the vagina, they shouldn’t be in your lube!), and has silicone to keep them “slippery” for the longest possible time. Water-based lubes tend to get tacky or sticky over a shorter time frame. Avoid any lube that says it will “enhance” pleasure. These generally contain l-carnitine or similar ingredients which heat and chemically burn the tissues. This can be excruciatingly painful!
By “lasers,” I am referring to the MonaLisa Touch, as it is the only one that has done the studies to show actual benefit in menopausal women. There are many other devices on the market, which may or may not work, but they do not have the data to back them up.
In my experience (and based on outcomes data and small comparative studies) the laser can work for 85-95% of women with vaginal symptoms. It works best within 15 years of menopause (though I have a few patients 20+ years out who swear by it!) It also helps a lot with incontinence issues. You need to get three treatments up front (spaced at 6 weeks) but then only annual touch ups are required. Unfortunately this therapy is not covered by insurance, and can be costly.
Eight: What do you tell a woman who’s nervous about the health effects of hormone replacement therapy (HRT)?
First of all, I never discount that feeling. You are right to be cautious, especially given the history of the medical field ignoring the effects of medications on women and poor testing on women.
Thankfully, as more women become doctors and researchers, we are slowly making strides in changing that bias. That being said, we have many years of data on hormones now, and I feel we have a good idea of how they work, what the major risks are, and where we see benefit.
Some important points:
- HRT or hormone therapy treats symptoms. Though it can have some bone health benefit and possibly some minor cardiovascular benefit (in a subset of women), we use it only for the symptoms of menopause, specifically hot flashes, night sweats, insomnia, and vaginal symptoms.
- All hormones have risks. There is no formulation that is “safer” or “more like your body’s natural hormones.” “Bio-identicals” have become popular, and those promoting them sometimes say that they can match your body (impossible, if you are in menopause, your hormone levels are gone, there is no way to test or know what they were before), that they are a more natural version (nope, just hormones compounded together, same chemical structure), or that they are lower risk (nope, this is a lie. All hormones have risks, you should be informed of all of them). There are many types of hormone generated by pharmaceutical companies that come from different places and have different ingredients, so discuss with your doctor what is available. Additionally the compounded hormones are not regulated, and when tested have been shown to contain anywhere from 12-400% of the amount of hormone they are supposed to. With a medication that can have risks, that level of variation makes me nervous.
Nine: Do you ever discuss alternative options for menopausal or vaginal issues? Herbals, acupuncture, etc.?
I do discuss these with my patients. There are several herbs marketed for menopausal symptoms. I find that most commonly women are taking raspberry leaf, soy products, or black cohosh.
Well-constructed medical studies have not shown great benefit from these therapies (ie: similar to placebo) but about 12-25% of women will get some benefit from even a placebo, so if they work for you, there is no harm or risk to trying,
Acupuncture also shows about a 25% benefit, so I don’t see harm in trying. I do recommend that you investigate the practitioner as best you can to make sure they have good training and are licensed.
There are other supplements I do not recommend. DHEA is sold as an oral over-the-counter for body builders and increasingly for menopause. It is a pre-cursor to estradiol and testosterone. If you take too much, your body will convert it to testosterone. You can see facial hair growth and voice changes, and these can not be reversed, even if you stop the medicine.
I also am very cautious with thyroid supplements in patients without diagnosed thyroid disease (people are often given Armour thyroid). Thyroid hormone will make you feel energetic and lose weight, but it will, over time, damage your heart and can lead to long-term health effects. Thyroid should always be dosed and followed with blood tests by a professional.
Ten: A lot of women claim their doctors are too dismissive of midlife complaints, of women’s pain, or are not well-informed about menopause. Do you think that’s true, and how do we move forward? How do we train the next generation of ob/gyns to be more responsive?
I think this has, in the past, been very true. I believe as more women enter medicine and as more of the female doctors reach menopause, that this will change. This is not to say there aren’t male doctors who are good at this, I just think women have more empathy for the symptoms. I think medical education has started to focus more directly on women’s health, but we certainly have a long way to go.
The best way to find a doctor who is going to be sensitive to this is to look at the NAMS website. Doctors can voluntarily take an exam through this organization which tests their knowledge of menopause medicine. Those who pass are certified as expert in this type of medicine.
Eleven: Is there a time when a woman no longer needs the care of an ob/gyn? When and why or why not?
Yes and no. Women may age out of needing OB/GYN care routinely if they don’t need frequent pap smears, and if they are not using hormones. It is good to have an OB/GYN you can see for any problems, however, and getting a pelvic exam (with or without a pap smear) continues to be important for cancer screening into older age along with breast exams.
If you’re suffering from vaginal issues, don’t hesitate to talk with your doctor. Please don’t use this blog or any other similar online resource to self-diagnose: articles such as this should not be considered a replacement for treatment by a healthcare professional.
Have you had vaginal issues? What happened, and how are you putting things right? We’d love to hear from you, so please share in the comments below (you can share anonymously, if that’s more comfortable for you), on our Facebook page, or in Midlife & Menopause Solutions, our closed Facebook group.
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