Vaginal and vulval problems

Dry vagina

Vaginal lubrication
The natural moistness of the vagina prevents its sides from rubbing against each other as you move about during the day. The vaginal moisture is also slightly acidic, and this helps to keep infections such as thrush at bay. This acidity is caused by the ‘friendly’ bacteria that live in the vagina and help to keep it healthy.

Vaginal moisture is mainly produced by the cervix (neck of the womb) at the top of the vagina and eventually oozes out of the vagina – some vaginal discharge is normal. This means that there is a very slow flow of moisture through the vagina, and this keeps it clean, as it moves dead cells and the remains of the menstrual period to the outside. On average, a woman discharges 2 g of dead cells and 3 g of mucus through the vagina each day

During sex. When you are sexually excited, two special glands at the entrance of the vagina, called Bartholin’s glands, produce extra secretions. The moisture from these glands is more slimy than the moisture from the cervix, because its purpose is to provide good lubrication during intercourse. Its musky smell is the result of millions of years of evolution to increase female attractiveness to the male of the species, and signals that the woman is ready for sex.

Dryness before the menopause
Vaginal dryness before the menopause is mostly a problem during sex. It may mean that you are not sufficiently aroused – which can occur for all sorts of reasons such as inadequate foreplay, feelings of guilt, fear or relationship problems. Also remember that men generally get aroused sooner than women, so your partner may be attempting penetration before you are ready, before good lubrication has occurred. Lack of lubrication is also common in breastfeeding women, because oestrogen levels are low, and in women with diabetes.

Dryness during or after the menopause
Vaginal dryness can be a particular problem at and after the menopause, because of a lack of oestrogen (the female hormone). Oestrogen is responsible for the plumpness of the lining of the vagina, for the elasticity of the tissues round the vagina and for the production of the moisture from the cervix.

Oestrogen levels fall at the menopause, so the vagina loses some of its elasticity, its lining becomes thinner and it feels dryer. Because there is less moisture, there are fewer of the ‘friendly’ bacteria that help to keep the vagina acidic. When the vagina becomes less acidic, infections such as thrush can take hold, which cause further irritation and discomfort.

All these changes can make intercourse uncomfortable. Another factor is that after the menopause, the Bartholin’s glands are less efficient – they take longer to produce the lubricating juices for sex, and produce less than in younger women. The American sex researchers Masters and Johnson showed that whereas younger women may become sufficiently aroused for penetrative sex in as short a time as a few seconds, menopausal women may take 5 minutes or more.

What to do about dryness before the menopause
A dry vagina can be lubricated easily. For additional lubrication for intercourse, use a water-soluble, starch-based lubricant (for example, KY jelly) or a vaginal moisturizer (for example, Sylk, Replens or Senselle) rather than a petroleum-based product like Vaseline, which may interfere with your natural secretions. Apart from Sylk (see Useful contacts), which is available by mail order and from some stockists, these products can all be bought from a pharmacy – you do not need a prescription. Sylk is a lubricant derived from an extract of kiwi fruit; obviously you should not use it if you are allergic to kiwi fruit. It has a non-sticky texture very similar to natural vaginal lubrication. Some lubricants damage condoms; Sylk, KY jelly, Replens and Senselle do not.

Sylk and KY jelly are used just before intercourse. Smear the product liberally over the vulval area, particularly round the opening of the vagina.

Replens and Senselle are moisturizers that you use two or three times a week. They coat the inside of the vagina with a non-hormonal moisturizer, which lasts for a day or two, so they do not have to be used immediately before intercourse.

What to do about dryness during and after the menopause
Leisurely sex with lots of foreplay. Taking time during sex is particularly important for the older woman. This allows the Bartholin’s glands to produce the maximum amount of lubrication before penetration.

Simple lubricants, such as KY jelly, or moisturizers, such as Replens or Senselle, can be used if you need additional lubrication for intercourse.

Hormone replacement therapy (HRT) will increase vaginal lubrication and thicken the vaginal lining, but has risks. Therefore, HRT is not appropriate if vaginal dryness is your only problem; there are safer ways of dealing with dryness.

Vaginal oestrogen creams can be prescribed by your doctor if you prefer not to take HRT. For the first 2 or 3 weeks you use it every night, and it may be a week or two before you notice any improvement. After that, twice a week will be enough.

The creams can be messy. Some come with a special syringe (applicator) to help you insert the cream into the vagina. In fact, the applicators are more trouble than they are worth, because they have to be washed in warm soapy water after each use. More importantly, they tend to give you too much cream. Some of the oestrogen will then be absorbed through the vaginal wall into the bloodstream, where it could be harmful. It is better to smear the cream inside your vagina with your fingers, and not to be over-lavish. If you are not used to touching the inside of your vagina you may find this peculiar at first, but you will very soon become quite relaxed about doing so.

Unless you have had a hysterectomy, oestrogen in the bloodstream needs to be balanced by progesterone tablets, otherwise there is a slight risk of cancer of the uterus (womb). Hormone replacement tablets provide both oestrogen and progesterone, but vaginal cream contains only oestrogen. Some of the oestrogen from the cream will enter the bloodstream through the walls of the vagina. Therefore, to be on the safe side, some doctors prescribe progesterone tablets for women using oestrogen vaginal cream.

Because some oestrogen from a vaginal preparation (whether it is a cream, tablets or ring) may enter the bloodstream, there have been worries that it could cause health risks like HRT. So far, there is no evidence for this (Cochrane Database Systematic Review 2003:CD001500), but research is ongoing.

Vaginal oestrogen tablets are another possibility. They need a doctor’s prescription. Each tablet comes in an applicator, which is about the size of a pencil. You insert the applicator into the vagina and press the end to release the tablet into the vagina. For the first 2 weeks you use one tablet a day, but later only two a week are needed.

Oestrogen-containing vaginal ring. This type of ring may be suggested by your doctor. The ring gradually releases oestrogen into the vagina. It has to be replaced every 3 months, and you must not use it for more than 2 years in total. It is not painful or uncomfortable, but you might feel a slight irritation at first. Some people find that it gets in the way during intercourse, in which case you can remove it beforehand and put it back afterwards. It is easy to take in and out – your doctor will show you how.

Black cohosh capsules can be bought from health food stores. Black cohosh comes from the root of a plant. It is commonly used for menopausal symptoms in Germany. A study in 1987 in Germany found that black cohosh had an oestrogen-like effect on the lining of the vagina, which might translate into better vaginal lubrication. However, this study has been criticized because, surprisingly, it also showed that oestrogen had little effect; scientists therefore think that the study may not be reliable. Black cohosh may cause liver damage; more research is needed.