Doctor, Why Does It Hurt Down There?

Over 60% of women in menopause complain, often silently, of vaginal dryness and pain during intercourse. As a consequence, they may seek to avoid that level of intimacy, a behavior that can impact negatively on their relationships and, for some, may lead to loneliness and depression. Why?

During the reproductive years, estradiol, produced by the ovaries, is important for health of the vagina, vulva, and lower bladder. Estradiol stimulates nitric oxide, a dilator of blood vessels, to deliver blood with its high water content to the pelvis. This moisture is drawn into the tissues because of the differing concentrations of sodium, potassium, and chloride between blood and vaginal secretions.  These ions are important for regulating vaginal lubrication. Estradiol also stimulates the growth of lactobacillus, healthy vaginal bacteria that metabolize glycogen anaerobically to lactic acid in order to maintain the acidity of the vagina at 4 +/-.05, a pH that is hostile to many sexually transmitted infections.  Deeper within the tissues, estradiol protects collagen to maintain support and integrity of the vagina, vulva, and bladder.

During menopause, vaginal tissues become dry and shrink. Why? Estradiol’s decline results in a reversal of its tissue-protecting effects. Blood vessels decrease in number and size, thus, reducing tissue moisture. Lactobacillus that formerly maintained acidity of the vagina disappear, leading to more alkaline vaginal secretions (normal postmenopausal vaginal pH is 6 to 7.5) and a greater risk of infections. Even the bladder becomes more susceptible to urinary tract infections (UTI).  But what makes the vaginal area so vulnerable to these infections? That question takes us to the heart of the problem.

Declining levels of ovarian estradiol lead to chronic inflammation in these tissues, as other cells begin to produce inflammatory proteins that had been chronically suppressed by higher levels of estrogens during the reproductive years. It is the emergence of inflammation in the vaginal area that promotes the repeating infections that women experience. It also explains the pain on intercourse, as vaginal manipulation occurs in the setting of these inflamed tissues.

Systemic hormone replacement may reduce vaginal dryness, but it is not for everyone. Local hormonal therapy in the form of estradiol cream applied to the vagina in small amounts reverses many of these inflammatory-induced effects. However, some women, especially breast cancer survivors, usually are told not to use vaginal estrogen cream due to their risk of increased estrogen blood levels above the normal menopausal range. Yet, due to the estrogen-blocking drugs that many breast cancer survivors take, the problems of vaginal dryness are greater than those of normal menopausal women. Current studies now indicate that androgen creams made of testosterone or dehydroepiandrosterone (DHEA) may offer relief without increasing estrogen blood levels.

Vaginal dryness affects the majority of menopausal women. Fortunately, systemic hormone therapy and local therapies such as estrogen and androgen creams, moisturizers, lubricants, and pH balancers now are available to help.

By James Woods, M.D.
Dr. Woods treats patients for menopause at the Hess/Woods Gynecology Practice.

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James Woods | 11/2/2015