Vaginal Estrogen For Everybody!

...with a vulva and vagina

It’s almost my birthday (summer baby, Leo, sun worshiper) and while there isn’t much to look forward to with turning 44, it has me thinking about my next birthday. And why is the prospect of turning 45 more exciting to me? Because that’s when I am choosing to start using vaginal estrogen! And I am choosing to write about it now because it’s an option worth considering for folks with vulvas and vaginas. Hear me out.

Last fall I signed up for Pelvic Global’s virtual conference on perimenopause and menopause. Sadly, I was unable to attend “live” because I was at a different course for the sexuality counseling program I was enrolled in and everything always happens on the same weekend.Thanks for reading All Pelvic Health! Subscribe for free to receive new posts and support my work.During the sex counseling course that weekend - “Sex-Related Assessment, Diagnosis, and Treatment of Psychosexual Disorders in the Current DSM” (what a mouthful) - the very smart, engaging and well educated lecturer Elizabeth Gandee said “I think everyone should start vaginal estrogen in their 40s or 50s” and my ears perked right up. Everyone?

For some background, I often see folks with signs of vulvar and/or vaginal atrophy (terrible name and we’ll get to the details in a minute) and suggest they start using vaginal estrogen. As a physical therapist I don’t prescribe medicine, so I help them make a plan for asking their provider to prescribe it and send their provider my exam findings to support the recommendation.But this is in response to symptoms that are already present due to body changes that have already happened. It did not occur to me that some providers working with folks in perimenopause and menopause are prescribing vaginal estrogen to stop the changes from happening in the first place.

Fast forward to this month when I finally got a chance to watch recored lectures from the Pelvic Global menopause conference. I heard not one but two very smart, engaging, and well-educated doctors, Dr. Fenwa Milhouse and Dr. Rachel Rubin, reassert this idea that low dose vaginal estrogen can (and should!) be used as preventative medicine. Ok, heard!

So let’s back up a little bit, what is vaginal estrogen for?

During the menopause transition bodies go through a lot of changes, most famously they stop having periods. They also makes less estrogen and progesterone which has an impact on every system in the body because hormone receptors are EVERYWHERE.Common perimenopause and menopause symptoms include hot flashes, brain fog, joint pain, sleeplessness, anxiety, cardiac symptoms, changes in metabolism, and changes to the vulva and vagina.

There are two ways to treat menopause systems with hormones.

Systemic hormones administered as creams, pills, patches or pellets that increase the amount of hormones circulating in the blood stream. Estrogen and progesterone or progestin are the most commonly prescribed systemic hormones for menopause symptoms. They are used to treat systemic symptoms like hot flashes, brain fog, anxiety, sleep issues, and cardiac issues. Testosterone is also sometimes prescribed systemically for symptoms related to libido and energy.

Local hormones administered as creams, vaginal tablets/gels, or vaginal rings act only on the tissue they come into contact with (i.e. the vaginal and vulva). They are used to treat a cluster of symptoms known as the genitourinary symptoms of menopause. These symptoms include…

Genital Symptoms:

• Vaginal dryness, burning, or discharge

• Genital itching

• Pain or discomfort during sexual intercourse

• Bleeding after intercourse

• Vulva pain with sitting, walking, or urinating

Urinary Symptoms:

• Burning, urgent, or frequent urination

• Increased risk of urinary tract infections (UTIs)

• Urge incontinence (leaking urine when trying to hold it)

• Stress incontinence (leaking urine with coughing, sneezing, or laughing)

• Painful urination

The vulva and vagina love estrogen so much. It keeps the tissues plump and healthy and promotes adequate blood flow. Without it, these tissues can start to atrophy (hence the horrible name) which, as you might imagine, can create a lot of problems. In this case when we say atrophy we mean…

• Thinning vaginal walls

• Loss of rugae (the ridges inside the vagina that allow for it to stretch)

• Narrowing vaginal opening

• Shrinking labia minora

• Shrinking clitoris

• Clitoral phimosis (when the hood of the clitoris adheres to clitoris or begins to cover it)

• Loss of lubrication

Arousal can become more difficult, sex can become painful, orgasms can be harder to come by (pun intended), and compromised tissues are more susceptible to infections such as UTIs. These issues are so pervasive for people during the menopause transition and post menopause that it’s right there in the name - genitourinary symptoms of menopause. And they are often under-treated or not treated at all.

Recent studies show that 59% of post menopausal women do not want or engage in sex because of their long term vaginal symptoms. That makes me so sad.It’s sad because it’s unnecessary. There is fear among some providers that any kind of hormone therapy can increase risk for things like breast cancer, blood clots, and stroke. We know that isn't the case. Studies show that when dosed and administered appropriately, vaginal estrogen does not increase systemic levels of estrogen beyond what is considered normal.This means that the estrogen that is placed in the vagina and on the vulva gets used up by the vagina and vulva and doesn’t absorb into the rest of the blood stream.This also means that it doesn't have an impact on other systemic symptoms of menopause like hot flashes, brain fog, joint pain, etc. Some people with bothersome systemic symptoms may decide with their provider that it is appropriate to take systemic hormone therapy to address these symptoms. It is safe to use both systemic and local hormones for many people.

But back to the vaginal estrogen. One reason that some providers that work in the field of sexual medicine recommend starting vaginal estrogen at the onset of menopause (around age 45) is to prevent these changes from happening in the first place rather than treating them after the symptoms have started. The genital changes caused by menopause are progressive, meaning that they keep getting worse. If you can stop that train before it leaves the station, why wouldn’t you?In terms of administration, vaginal estrogen comes in three basic forms: creams, inserts, and the ring.People have many reasons for choosing their preferred vehicle for vaginal estrogen including…

• Ease of use

• Dosing consistency

• Dexterity

• Comfort level

• Cost

Gynecologist and menopause expert Dr. Jen Gunter compiled a ton of research to write a deep dive into the types of vaginal estrogen available and their pros and cons. This wealth of info is here: https://vajenda.substack.com/p/a-deeper-dive-into-vaginal-estrogens?utm_source=substack&utm_campaign=post_embed&utm_medium=web

At the end of the day it is a personal choice. Some of my clients feel that vaginal estrogen is not right for them. I validate that choice and celebrate them for making it. There are other things you can do to mitigate these changes.

Have sex! If sex is not currently painful, do it and do it often. Solo or partnered. Doesn’t matter. It’s a use it or lose it situation. Vibration (hello, toys!) and penetration increase blood flow to genital tissue and helps to keep it healthyUse hyaluronic acid as a personal moisturizer. This draws moisture to the tissues helping them stay plump and lubricated. This is used regularly in the vagina, not during sex.

Use lube. This is used during sex! Water based and silicone based are both good options. Sometimes silicone based can offer more slickness and friction prevention per application than water based but go with your personal preference. I will likely do a lube explainer in the future, so stay tuned :)

If you are having pain with sex, see someone! Loop in your sexual health practitioners - urologists, gynecologists, pelvic floor physical therapists, sex counselors and therapists. The longer it goes on the more your body associates sex with pain which makes the pattern more challenging to disrupt.

When I told a friend about my plan they asked how it made me feel. I said with glee, “excited!”. This got a strange look…who would be excited about starting a medication that would have to be used for the rest of their life? I told them I am excited to have some control over my story about this time in my life. It is easy to be overwhelmed by stories of pain and distress and sexlessness and to think that it is inevitable. Knowing what to expect is powerful. Knowing what to do (even if vaginal estrogen is not for you) is more powerful. Take pride in writing your own transition story.