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Vaginal and Vulvar Comfort: Lubricants, Moisturizers, and Low-dose Vaginal Estrogen

If you are having mild vulvar irritation or discomfort, the first thing to do is stop using soap on the inner parts of your vulva. Clean water is perfectly adequate for washing there. Also, use only white unscented toilet paper, wash your underwear in detergents without dyes and perfumes, and stop using fabric softeners and anti-cling laundry products. Avoid using lotions and perfumed products on the inner vulva as well. 

Menopause-related vaginal dryness often leads to pain with penetration and during deep intercourse, and can be associated with arousal difficulties as well. Many different topical vaginal treatments are available, from nonprescription, nonmedicated lubricants and moisturizers to prescription-only topical forms of estrogen therapy (see table).

Examples of commonly used lubricants, moisturizers, and vaginal estrogen products

Water-based: Astroglide, FemGlide, Just Like Me, K-Y Jelly, 
     Pre-Seed, Slippery Stuff, Summer’s Eve, others
Silicone-based: ID Millennium, Pink, Pjur, Pure Pleasure, others
Oil-based (avoid): Mineral oil, Elegance Woman’s Lubricant, others

Vaginal moisturizers Fresh Start, K-Y Silk-E, Moist Again, Replens, K-Y Liquibeads, others
Vaginal estrogen products Vagifem (vaginal tablet), Estrace (cream), Neo-Estrone (cream), Premarin (cream), Estring (low-dose vaginal ring)

Lubricants and moisturizers are effective in relieving pain during intercourse for many midlife women with mild to moderate vaginal dryness, so these products are a natural place to start. That’s particularly the case for women who are not candidates for vaginal estrogen therapy or are not comfortable using it.

Vaginal estrogen products deliver estrogen directly to the vagina, with minimal absorption to the rest of the body, and restore thickness and flexibility to vaginal tissues.

If you have more severe vaginal dryness and related pain, or if lubricants and moisturizers don’t work well for you, see your healthcare provider. There may be a more serious cause of your discomfort that should be diagnosed and treated. You and your healthcare provider can also discuss low-dose vaginal estrogen products. These prescription-only products deliver estrogen directly to the vagina, with minimal absorption to the rest of the body, and restore vaginal tissue thickness and flexibility. These actions may help prevent other sexual problems (such as worsening pain during sex, vaginismus, or diminished arousal or orgasm) that can result from chronically painful sex.

Lubricants. Vaginal lubricants work by reducing the friction associated with thin, dry genital tissue. They come in liquid or gel form and are applied to the vagina and vulva (and, if desired, to a partner’s penis) right before sex. Lubricants are not absorbed into the skin, are immediate-acting, and provide temporary relief from vaginal dryness and related pain during sex. They are particularly appropriate for midlife women whose vaginal dryness is an issue only or primarily during sex.

A wide variety of lubricants are commercially available, either as water-based, silicone-based, or oil-based products. Water-based lubricants have the advantage of being nonstaining. Oil-based lubricants (such as petroleum jelly and baby oil) should be avoided, as they can cause vaginal irritation and are associated with high rates of latex condom breakage that can lead to sexually transmitted infections. Polyurethane condoms do not break with oil-based lubricants.

“Warming” lubricants: Mixed responses

Most lubricants are intended to temporarily address vaginal dryness, but some “warming” or “zesty” lubricants are marketed to enhance sexual response and function. These products cause a warming sensation on the skin that’s triggered by ingredients such as capsaicin (a component of chili peppers) or menthol. One of the warming lubricants, Zestra, has been shown to enhance sexual response in research studies. While some women experience pleasurable warming sensations with these products, others report that they cause stinging or burning pain.

Moisturizers. Like lubricants, vaginal moisturizers reduce the painful friction that sex can cause as a result of vaginal atrophy. Additionally, moisturizers, unlike lubricants, are absorbed into the skin and cling to the vaginal lining in a way that mimics natural secretions. Another difference is that moisturizers are applied regularly, not just before sex, and their effects are more long-term, lasting up to 3 or 4 days. Some moisturizers have an applicator to help place the product into the vagina.

For both moisturizers and lubricants, you may need to experiment with several products to find the one that’s best for you.

Because moisturizers maintain vaginal moisture and acidity, they are particularly appropriate for midlife women who are bothered by symptoms of vaginal dryness (such as irritation and burning) that are not limited to sexual activity. Some women who regularly use moisturizers still use a lubricant as needed before sex, for additional lubrication and comfort. For both moisturizers and lubricants, you may need to experiment with several products to find the one that’s best for you.

Low-dose vaginal estrogen therapy. Estrogen products designed for vaginal application have been proven to restore vaginal blood flow and improve the thickness and stretchiness of vaginal tissue in peri- and postmenopausal women. These products act to reverse the thinning and dryness of vaginal tissues rather than just providing the temporary relief that lubricants and moisturizers do.  For this reason, low-dose vaginal estrogen is appropriate in most cases for peri- and postmenopausal women who do not get sufficient relief from moisturizers or lubricants or whose symptoms of vaginal atrophy are interfering with their quality of life.

Severe vaginal atrophy may respond more quickly to vaginal estrogen therapy than to hormone pills or patches.

Women who need relief from other significant symptoms of menopause, such as hot flashes and night sweats, may want to consider higher-dose hormone therapy that raises estrogen levels throughout the body, as discussed on the next page of this program. However, for women without those other menopause symptoms, vaginal estrogen should be used since it is concentrated where it is needed and minimizes blood levels and possible side effects of estrogen on the rest of the body. Additionally, severe vaginal atrophy may respond more quickly to vaginal estrogen therapy than to hormone pills or patches that deliver estrogen throughout the body.

Vaginal estrogen should be used at the lowest effective dose, again to limit any effects elsewhere in the body. If you’ve had breast cancer, be sure to mention this to your healthcare provider before using estrogen in any form so that you can properly weigh its benefits and risks.

Low-dose vaginal estrogen is very effective against atrophy-related pain during sex, with up to 93% of women reporting significant improvement and 57% to 75% reporting that their sexual comfort is restored.13-17 Improvements in vaginal moisture and health typically occur within a few weeks of starting therapy, although relief from severe vaginal atrophy can take several months.

Vaginal estrogen is available in several forms, all of which require a prescription:

  • Vaginal creams are applied in small amounts (0.5-1.0 g) in the vagina 2 to 3 times a week. These products, known by the brand names Premarin, Estrace, and (in Canada) Neo-Estrone, should not be used as a lubricant before intercourse since the estrogen can be absorbed through a partner’s skin.
  • The low-dose vaginal ring, Estring, is inserted into the vagina and worn for 3 months before being taken out and replaced; it does not need to be removed before sex. This low-dose estrogen ring is designed only to treat vaginal dryness and should not be confused with Femring, which is another vaginal ring that releases higher doses of estrogen for treating hot flashes and other symptoms of menopause.
  • The vaginal tablet, Vagifem, is placed in the vagina twice a week using an applicator (recommended) or a finger. Many women find the estrogen tablet less messy than estrogen creams.

All forms of vaginal estrogen are similarly effective, and most forms are associated with minimal side effects, although women’s individual responses may differ. The form chosen should be based on your individual preference, factoring in cost and insurance coverage, after discussion with your healthcare provider.

If low-dose vaginal estrogen therapy is right for you, you may also use lubricants and moisturizers as needed. Sometimes, after estrogen therapy has restored the vaginal tissues to a more healthy state, it can be stopped and nonhormonal lubricants or moisturizers can be used alone. To maintain the benefit, however, it is important to continue regular vaginal sexual activity.

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