Who doesn’t want a physically and emotionally fulfilling sex life? POP symptoms such as tissues bulging out of the vagina and pain with intimacy are far too often roadblocks to sexual bliss. While the emotional distress women experience regarding organs and tissues peeking out of the vagina during sex-play may hinder engagement, pain with intimacy can shut the door completely. As common as vaginal atrophy is, it often persists untreated.
You don’t have to suffer with atrophy!
Estrogen loss related to menopause and perimenopause is considered the 2nd leading cause of POP. Beyond the loss of muscle tissue strength and integrity, estrogen depletion as we age may result in vaginal and vulval tissue atrophy, causing tissues to become irritated, thin, dry, and less supple. Vaginal secretions are reduced, resulting in decreased lubrication during sex. Dry, itchy, fragile vulvovaginal tissues are susceptible to injury, tearing, and bleeding during intercourse. Intimacy may become so painful that sex stops occurring at all. When a woman does not engage in intercourse regularly during and following menopause, the vagina may become shorter and/or narrower, causing pain when intercourse is attempted, even when using a lubricant. Atrophy can be a considerable roadblock for women already struggling with POP related self-esteem issues. The impact to sexual satisfaction and relationships can be devastating.
Michael Goodman, MD, a world-renowned Menopause and Sexual Medicine specialist as well as a Cosmetic Gynecologist, has spent decades providing innovative and integrative women’s healthcare. As a surgeon, teacher, author, and menopause expert, he shines a light to clarify reality vs misconception regarding atrophy. A phone call to Dr. Goodman quickly shifted from a casual conversation into a valuable class in hormone therapy.
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Q Women often fear traditional hormone replacement therapy (HRT). Can you clarify the difference between HRT and bio-identical hormone replacement therapy?
The difference between bioidentical hormone replacement therapy (BHRT) and hormone replacement therapy (HRT) is often misinterpreted, so let’s begin by clarifying the difference between BHRT, HRT, and compounded hormones.
There are 3 types of estrogen in women, estriol (E3), estradiol (E2), and estrone (E1). Estradiol is the most commonly used estrogen in hormone replacement therapy. Estradiol can be considered the “natural” replacement since it is the estrogen in women’s ovulatory follicles the ovaries used to produce prior to menopause. Estrogen is available in pill, patch, oil, suppository, gel, injection, vaginally inserted ring form, by means of oral or transdermal (absorbed into the body through the skin) transfer. Estrone is the most risky estrogen related to the breast tissue, and estriol is the estrogen produced by the placenta in pregnant women, not by the ovary.
Estrogen, progesterone, and testosterone are isomers (compounds with an identical chemical formula), structures that may be synthesized in the lab by splitting off side chains from “plant sterols” such as wild Mexican yams or soybeans to produce the biologically or molecularly identical compounds used in the so-called bioidenticals. The hormone Premarin, which until the past 10 years was the most commonly prescribed hormone replacement, can be considered “natural” as it is directly produced from a “natural” source (pregnant mares’ urine), which contains 10 different estrogenic compounds. BHRT by definition is not truly “natural” (coming directly from a plant or animal source) but is derived from a natural source. Since yams, soybeans, and horse urine are all plant/animal sourced, they all technically fit into the “bioidentical” format. However, what is of significance is how precisely and appropriately they are utilized within the body to generate the most benefit with minimal to no side effects.
Compounding hormones is a blending of different kinds of hormones into a variety of dosages and dosage forms, creating multiple options to provide a more targeted benefit to suit women’s individual needs, such as combing E2, progesterone, testosterone, and perhaps others into a single application product. Compounded hormones are usually less expensive if you do not have insurance covering these types of hormone replacement therapies. Compounded formulations do not undergo the strict manufacturing and purity standards testing that their FDA-approved counterparts such as Premarin do; however, despite this unregulated environment, compounded hormones are widely popular with patients seeking more “personalized” medicine.
Interestingly, all of the estradiol (E2) in the world to my knowledge comes from one of two companies in Germany, Mallinckrodt Pharmaceuticals or Organon Pharmaceuticals. These compounds are either sold to Pharma, who make such products as Vivelle Dot, Climara patch, DiviGel, Estrace (estradiol tablets) etc., or sold to wholesalers, who sell directly to compounding pharmacies. They all can be considered “BHRT”.
So… while the term “BHRT” usually refers to the compounded product, in truth there are two types of bioidenticals, “FDA-Approved” (which have been tested for purity and concentration) and “compounded bioidenticals” which are not. While both are inherently safe, especially if you know and trust the compounder, commercial bioidenticals are inherently safer than the compounded ones, as they have been FDA tested and received approval. Compounded bioidenticals are what is called “off-label;” traditionally utilized for a specific purpose, but not officially approved for usage. As dosing and application sites have not been standardized, and as many clinicians use robust (compounded) dosing, BHRT must be considered less safe than so-called “traditional HRT.” Thus, it is imperative that, if compounded BHRT is used, the specific practitioner prescribing should be researched. I would hope the provider is a gynecologist or a hormonal medicine specialist, and not a med-spa provider.
Q Please distinguish the difference between lubricating gels and creams vs hormone replacement therapy to replenish vaginal moisture.
Lubricating gels and creams lubricate. Vaginal HRT, whether estradiol, estriol, DHEA, or testosterone, nourish, normalize, and regenerate the vaginal skin to be able to stretch better and self-lubricate without burning or tearing.
Q Is there any benefit to introducing low-dose estrogen therapy early to prevent or reduce atrophy?
There is huge benefit to this. As my grandma used to say, “an ounce of prevention is worth a pound of cure”. Local vaginal and perineal HT containing micro doses of any of the above hormones (question 2) singularly or in combination, is both wildly successful and not considered traditional systemic HT. The doses of vulvovaginal therapy contain per week the same amount or hormone exposure as HRT or BHRT does per day.
Q Can you speak to “shrinkage” of vaginal length, width, and the vaginal opening that occurs with atrophy?
It is a “use it or lose it” phenomenon. When hormonal levels dive, the vaginal cells receive no nutrition and shrink or die, leading to what the question describes. Again, “…ounce of prevention…” The “cure…” takes time, but is usually fully successful, and consists of first developing vaginal health, then slowly dilating the vaginal length and caliber with progressive dilator therapy. This timetable may be shortened with the use of an EBD (Energy-Based Device) such as laser or radiofrequency (RF) treatments.
Q Is vaginal dilator use of value to treat atrophy, and if so, how should it be used, and when is it introduced?
Yes, effective. Use begins after the vagina and vulvar vestibule is well estrogenized, which usually takes ~ 6 months with HT, or ~ 3 months with laser + HT. In dilator therapy, cone-shaped, usually rigid plastic or hard rubber cones of progressively increasing length and/or caliber are utilized, until the vagina is of sufficient caliber and length to accommodate enjoyable vaginal intercourse.
Q What is your opinion of the use of bioidentical hormones vs laser or radio frequency to treat vaginal atrophy?
They both work and are viable options. As I wrote above, using vaginal micro dose hormone therapy is effective in more than 90% of patients, but takes a while. Use of laser or RF, especially if either micro dose E2 or E3 or DHEA is utilized after therapy, will speed up the process by 50%. But it will cost you $2500-$3000 and is not covered by insurance.
Q Clearly menopause is not the only cause of reduced estrogen levels. Can you clarify other possible conditions and causes, particularly those that may occur in women under 50?
The most likely cause of reduced estrogen levels in women under 50 is of course the lowering estradiol levels that occur with ovarian aging and loss of ovulatory follicles, as 50% of women go through menopause prior to age 50. Of course, any therapy, surgical, radiological or chemotherapy, that removes or eliminates ovarian function will cause estrogen levels to jump off the pier. Hysterectomy that removes ovaries results in immediate cessation of E2 levels. Smokers and diabetics lose ovarian function earlier. Liver disease may also alter estrogen levels.
Q In APOPS space, at the 6 week point post-surgery if a woman is still experiencing pain, the first thing she is concerned about is surgical complications. Can you clarify whether atrophy not having been addressed prior to POP surgery could be a possible source of post-surgical pain, and share your opinion regarding the use of vaginal estrogen pre and post-surgery as an adjunct therapy for post-surgical vaginal healing?
I reconstruct and rebuild vaginal floors. I work in exactly the same space as urogynecologists. It is rare that vaginal reconstructive surgery is an emergency or must be performed ASAP. It is my conviction, based on both clinical and histological data, that a healthy, well-estrogenized vagina will heal far better than an atrophic one, so if I am to operate on a peri/post-menopausal woman with vulvovaginal atrophy, I require a minimum of 3 months of vaginal therapy prior to surgery, and continuation of this therapy beginning 1 month after surgery. Simply put, a well-estrogenized vagina and vulvar vestibule is a healthy vagina and vulvar vestibule and will heal earlier and better.
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Atrophy can be a roadblock, whether we are evaluating it from the physical, emotional, sexual, or surgical comfort zone. Aging does not mean you have to put up with atrophy. Treatment for cancer does not mean you have to put up with atrophy. Lack of sex drive does not mean you have to put up with atrophy (although when optimizing both they nurture each other). And certainly, when a POP surgery has “gone well” and pain continues, estrogen may be your best friend.
#APOPS #womenshealthempowerment #EveryVoiceMatters