Experiencing hot flashes during the menopause transition is bad enough, but coincidental vaginal dryness removes the spontaneity from sex, predisposes to urinary issues, causes vaginal itching, and, for some, makes it uncomfortable to sit on our fannies. As estrogen diminishes during perimenopause, the vaginal lining thins, and its walls lose their folds.
These changes were originally diagnosed as “vaginal atrophy,” leading women to believe that their vaginas were shrinking from minimal sexual activity. Thankfully, the SWAN (Study of Women Across the Nation) findings discredited this assertion of “use it or lose it.”[1] Now called Genitourinary Syndrome of Menopause (GSM), it is easily diagnosed during a pelvic exam and there are numerous options to remedy it.
Over half of women undergoing the menopause transition experience vaginal dryness and pain with sex, but only about a third of them mention it to their doctor.[2] Sadly, many doctors are not up to date about GSM and their experience with lubricants may not extend past KY jelly usage for pelvic exams. Lubricants and moisturizers for this delicate area receive little safety or effectiveness oversight, which is discouraging, since they are considered the first line of therapy for GSM when no other major climacteric symptoms are present.[3]
About 1 in 6 women experience GSM symptoms during perimenopause, but most notice problems after their final period. As an internist (adult medicine doctor), I would treat women with urinary symptoms, but none mentioned vaginal symptoms as I suppose they considered this unrelated or under the purview of a gynecologist. Even as a patient myself, there was little to no guidance from my gynecologist on choosing a vaginal lubricant or moisturizer. So, here is some information to consider.
Unlike the premenopausal vagina, the post-estrogen vagina is much less tolerant to changes in its environment. Just as the GI tract has its own microbiome, the healthy premenopausal vagina also contains a characteristic array of bacteria. These beneficial bacteria create an acidic environment that is protective against invasive microbes, including many responsible for causing sexually transmitted infections (STIs), yeast infections, and urinary tract infections (UTIs).
With decreased estrogen, the bacterial mix changes, leading to reduced acidity. Douching, stress, excessive sex, and irritating creams or lubricants also negatively influence vaginal pH and thus, its defenses. The post-menopausal vagina produces fewer lubricating secretions which, along with using strong or scented soaps, predisposes to dry, itchy, or irritated outer vulvar tissues.
Prescription Hormonal Treatments
Women whose vaginal symptoms are affecting their daily life are motivated to see their doctor. Those with other co-existing moderate to severe menopausal symptoms are often offered systemic estrogens (pills or skin patch) which improve GSM symptoms to various degrees. Women who are not eligible for these systemic estrogens might be candidates for localized vaginal estrogen products which are felt to be safe for most women, even well past menopause. These act directly within the vagina to reverse vaginal “atrophy” yet have little effect on rest of the body. The classic prescription is estrogen cream, but vaginal estrogen is also available in other forms: tablets or suppositories which are placed in the vagina twice a week, or a silicon ring containing slow-release estrogen that is worn internally for 3 months and replaced every 90 days. Localized estrogen is also available in other forms: tablets or suppositories which are placed in the vagina twice a week or a silicon ring containing slow-release estrogen that is worn internally for 3 months and replaced every 90 days. Dehydroepiandrosterone (DHEA) is another intravaginal hormone product available by prescription which is also effective in improving GSM symptoms and correcting vaginal acidity. All are available only by prescription and costs vary widely.
Lubricants & Moisturizers
For those who cannot or don’t want to take any hormones and those whose treatment of vaginal dryness is incomplete, lubricants and vaginal moisturizers can directly improve symptoms. What should you consider when deciding? First, determine its primary use—a lubricant to be employed for sexual activity or a vaginal moisturizer to be used more regularly internally and/or externally? For peri-menopausal women who have mild vaginal dryness, applying a lubricant for sexual intercourse may be all that is needed. If genitourinary symptoms are more problematic, more frequent use of various vaginal moisturizers may help.
Most women start addressing their vaginal discomfort with lubricants especially since there is a vast array available from pharmacies, grocery stores, sex toy shops, and the internet. Lubricants are water-, oil-, or silicon-based and choices are made based on desired lubricant attributes and compatibility with the type of condoms or playthings being used. Compatibility with condoms is usually clearly marked on the packaging, but “lube” ingredient lists are written in a tiny font—if printed at all. (Don’t you hate pulling out your reading glasses only to find you need a magnifying glass too?!)
Each woman must also consider vaginal sensitivity for these choices. As with any purchase that is going in or on your body, look at the ingredient list. Fragrance-free (and color- and flavor-free) is best since the fewer possible sensitizers, the better. Warming agents tend to be irritants. You may wish to avoid preservatives such as parabens which are endocrine disrupters (chemicals that interfere with your hormones). Chlorhexidine is an antiseptic agent which could injure your beneficial bacteria. Spermicidal lubricants contain nonoxynol-9 which is toxic to sperm cells, and may irritate your vaginal lining.[4] Frequent use of lubricants with these ingredients is not advisable.
Surprisingly, vaginal safety of these products is not addressed by the US Food and Drug Administration (FDA) or European Medicine Agency because lubricants are considered “medical devices” by these entities! Any studies that have been done have been performed in test tubes or on animals (rodents, rabbits, and slugs). Yes, slugs.
Two important considerations for water-based lubricants are its acidity (measured by pH) and osmolality, or level of concentration, as measured in mOsm/kg. (Don’t let these chemistry words intimidate you.) Since the healthy vaginal pH ranges from 3.5 to 5, you would want to use a product with a similar acidic pH, especially since vaginal fluids trend towards neutral during the climacteric. Your beneficial bacterial will thank you and you may be less likely to incur a UTI or STI.
Highly concentrated products draw water out of your vaginal lining cells to keep the lubricant juicy. The World Health Organization (WHO) addressed lubricant osmolality and recommended that optimum values should be at or below 380 mOsm/kg although an acceptable range lies between 380 and 1200 mOsm/kg. Some products, like KY jelly used for gynecologic exams, have concentrations far greater than 1200 mOsm.[5] [6] Lubes containing glycerin, glycerol, or any glycol generally have high osmolalities. Glycerin and glycerol are also sweet and, while pleasant for your partner, yeasts may love them too. In short, lubricants with these ingredients are okay for infrequent, intermittent use but not as a moisturizer.
In the past, some water-based lubricants did double duty as moisturizers, but the vaginal moisturizer market is growing and newer “hydrating” products containing hyaluronic acid (HA) seem to be gaining ground. HA is found in the soft connective tissues underlying skin, between muscles and organs, in joint fluid, and within eyeballs, and is important for wound healing, too. It is also used by the cosmetic industry in hydrating skin creams and injectables to push out wrinkles or plump up lips.
While pricey, HA products for vaginal use are available without a prescription. Moisturizer options include suppositories, pre-filled single-use gel applications, and tubes of gel with reusable, washable applicators so you can adjust the dose. No surprise, HA is acidic, which benefits vaginal pH, but some may notice mild vaginal burning with initial use. In trying a gel product first, rather than suppositories, you can control how much you apply by starting with small amounts and increasing the quantity as your tolerance builds.
Since gels tend to liquify as they are warmed by the body, applying them at bedtime or wearing a pad is advised. If you are also using a vaginal estrogen, the recommendation is to insert vaginal moisturizers on different days or at least, separate the applications by at least 2 hours.
The few studies performed on vaginal lubricants and moisturizers focus on acidity, osmolality, and some of the common ingredients found in over-the-counter and Internet products, but most do not name specific brands. Moreover, at the time of writing, none of the moisturizers available by “subscription” have been independently evaluated. One review article evaluating these products listed the pH, osmolality, and ingredients for several named brands, and overall, the most vaginal-friendly lubes and moisturizers are produced by the Good Clean Love™, Ah! Yes™, and Balance Activ® companies.[7] * Many of these products are unscented, some are organic, and a few contain HA. Their only drawback as lubricants is that they may not feel slimy for as long as some other products since their osmolalities are at the low end of the WHO’s optimum range.
As previously mentioned, the vulvar area between the outer and inner labia can also become dry. This may be worsened by wearing panty liners or incontinence pads. You may also notice new irritation caused by previously tolerated feminine hygiene sprays. Applying unscented emollients like pure coconut, vitamin E, almond, or jojoba oils around the vulvar area and vaginal opening may be soothing. Using these oils as lubricants is also acceptable unless incompatible with condoms or toys. These products are available at grocery stores and pharmacies.
Inadequate response to the above remedies may indicate that GSM is complicated by other co-existing problems. In these cases, a gynecologist or menopause specialist should be further consulted for the best course of action.
*I have not been approached by nor have commercial interest in these companies.
The above information is for educational purposes and not intended to diagnose or provide treatment. Individual cases should be discussed with your gynecologist or see www.menopause.org for the name of a menopause specialist near you.
[1] Samar R. El Khoudary et al., “The Menopause Transition and Women’s Health at Midlife: A Progress Report from the Study of Women’s Health Across the Nation (SWAN),” Menopause (New York, N.y.) 26, no. 10 (September 23, 2019): 1213–27, https://doi.org/10.1097/GME.0000000000001424.
[2] D. Edwards and N. Panay, “Treating Vulvovaginal Atrophy/Genitourinary Syndrome of Menopause: How Important Is Vaginal Lubricant and Moisturizer Composition?,” Climacteric 19, no. 2 (March 3, 2016): 151–61, https://doi.org/10.3109/13697137.2015.1124259.
[3] Belal Bleibel and Hao Nguyen, Vaginal Atrophy, StatPearls [Internet] (StatPearls Publishing, 2021), https://www.ncbi.nlm.nih.gov/books/NBK559297/.
[4] Edwards and Panay, “Treating Vulvovaginal Atrophy/Genitourinary Syndrome of Menopause.”
[5] Ana Raquel Cunha et al., “Characterization of Commercially Available Vaginal Lubricants: A Safety Perspective,” Pharmaceutics 6, no. 3 (September 22, 2014): 530–42, https://doi.org/10.3390/pharmaceutics6030530.
[6] Edwards and Panay, “Treating Vulvovaginal Atrophy/Genitourinary Syndrome of Menopause.”
[7] Edwards and Panay.
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