The hormone fluctuations that begin in perimenopause bring about many physical changes. As estrogen and progesterone levels decline in late perimenopause and postmenopause, vaginal walls often become thinner, drier, less flexible and more prone to tears and cracks.
This can be particularly true for women who have never given birth or had only cesarean sections, as vaginal birth gives the walls a lasting stretch. Similarly, regular sexual activity helps maintain vaginal flexibility and pliability, presumably because it increases blood supply to the vagina and can also have a stretching effect.
Women who have thinning and inflammation of the vaginal walls — which many clinicians refer to by the term vaginal atrophy or atrophic vaginitis — may end up completely avoiding intercourse or other insertive sex because of discomfort.
The hormonal shifts of perimenopause may also result in less lubrication being produced, so it can take longer to become wet during sexual activity. Penetration may be uncomfortable or even painful, and can lead to irritation. If the tissue of the vaginal wall become very delicate, friction from sexual activity may cause bleeding.
Some prescription and over-the-counter drugs can cause or contribute to vaginal dryness. Antihistamines, for example, dry vaginal tissue as well as nose and eye tissues. Douches, sprays, and colored or perfumed toilet paper and soaps can irritate vaginal and vulvar tissues. There are also a variety of conditions, including vulvodynia, that can cause pain and/or irritation with insertive sex.
Vaginal dryness during sexual activity at any age may simply mean that you need more stimulation and maybe even to experience orgasm before penetration. Experiment with different types of stimulation to discover what feels best and is most arousing.
Here are some tips to relieve vaginal dryness and discomfort during sex:
- Wait until you are fully aroused before penetration.
- Lubricants such as Silk-E, Albolene, Astroglide, or Slippery Stuff are often helpful during sex. Vegetable oil is another option. (See: How to Choose a Lubricant for Pleasure and Safety.)
- If dryness persists, try an over-the-counter vaginal moisturizer, such as Replens. It can be used one or more times a week, but not at the time of penetration.
- Avoid scratching, which can irritate delicate tissues and lead to infections and further problems. (Itching is sometimes a sign of a yeast or fungal infection that needs treatment.)
- Graduated dilators may be used to gently expand your vaginal walls and increase elasticity. Start with a small size, and work your way up.
If lubricants and other strategies are not sufficient, there are several other strategies to try.
Low-dose local (vaginal) estrogens, in very small amounts, are highly effective at relieving vaginal dryness. They can also restore thickness and flexibility to the tissues in the vulva and vagina.
Preparations include Estring (a Silastic ring that you insert like a diaphragm and leave in for up to three months), Vagifem tablets, and Estrace and Premarin creams. There is also Estriol, a bioidentical vaginal cream made by compounding pharmacies. These products have a localized effect, so far less estrogen gets into the bloodstream than occurs with oral or transdermal (patch) estrogen medications.
The ring delivers a minuscule amount of estrogen to the bloodstream, and the tablets send a little more, though the dose delivered in the tablet has recently been reduced. Regrettably, there are no long-term studies that demonstrate if even these small amounts of estrogens have risks, but they definitely improve the quality of life for many women.
If you use a vaginal estrogen cream, keep in mind that it can send a larger and somewhat unpredictable amount of estrogen into the bloodstream, depending how much is used and how often it is used. Most women initially require nightly treatment, but many women find that a dose smaller than what’s prescribed works fine, especially if they are sexually active.
Try using just enough to cover a fingertip and apply it to the opening of the vagina; the applicators tend to deliver a systemic dose of estrogen and deposit it higher than necessary. Estrogen cream should not be used as a lubricant for intercourse because it can be absorbed through a partner’s skin.
If you’re among the small number of women who have persistently sore breasts while using vaginal estrogen, try decreasing the dose to see if that will eliminate the soreness. If soreness persists, consult your health care provider.
Hormone therapy (HT) that includes systemic estrogen is also effective at relieving vaginal dryness. However, since low-dose local estrogens work well, it is typically not necessary to resort to systemic HT.