Intimacy – of which sex is part – is the glue in any marriage, but it can get difficult for women to enjoy sex when approaching menopause.

For Life speaks to Dr Suresh Nair from Seed of Life, Fertility & Women’s Care Medical Centre at Mount Elizabeth Novena on what women can do about this.

(Q) Why do women stop having sex during menopause?

(A) The most common cause of vaginal atrophy is menopause, which most women go through in their mid-fifties. Before menopause, the oestrogen a woman’s ovaries make helps keep the skin of the vagina healthy and supple and also stimulates vaginal secretions. After menopause, the ovaries stop making oestrogen which causes the walls of the vagina to lose volume and suppleness, and vaginal secretions are reduced. About 75 percent of post-menopausal women experience some degree of vaginal atrophy

(Q) Are there any other causes apart from menopause?

(A) While menopause is by far the most common cause of this condition, it can also be caused by other factors such as medications or hormones used to decrease oestrogen levels in women, as part of the treatment for breast cancer, endometriosis, fibroids, or infertility. Radiation and or chemotherapy treatments can also cause it. In rare instances it can be the result of severe stress, depression, or rigorous exercise.

Although similar changes to vaginal atrophy can occur after childbirth or while breastfeeding (as oestrogen levels are lower at these times) these changes are temporary and less severe.

(Q) How does vaginal atrophy make sex painful for women?

(A) The natural lack of natural secretions or dyspareunia is the main cause of the discomfort women with the condition feel during intercourse. Without these to act as a lubricant, the vagina wall, which is already thinner and less supple, can be irritated and sore and painful.

(Q) Apart from making sex painful can vaginal atrophy cause other problems?

(A) Yes the condition can also cause redness, itching, and dryness and the appearance of the vagina and labia may change to look paler and thinner. Over time there may be narrowing and shrinkage of the vaginal opening and the vagina itself. This can result in irritation when wearing certain clothes such as tight jeans or tights and when doing some physical activities. It can also lead to an increase in urinary tract infections. Other urinary symptoms include painful urination, blood in the urine, increased frequency of urination, incontinence, and increased likelihood and occurrence of infections.

The vagina can also become further irritated from soaps, laundry detergents, lotions, perfumes, or douches, while smoking and certain medications may also cause or worsen vaginal dryness.

(Q) Can vaginal atrophy be treated and if so what are some of the treatment options?

(A) If the symptoms are mild and limited to dryness they may be relieved by using a water-soluble vaginal lubricant during intercourse. If the condition is more serious, Hormone Replacement Therapy (HRT) may be prescribed to increase the whole body’s oestrogen levels. Although HRT is generally considered safe and effective by doctors, some women worry about the long-term risks of taking it. They may prefer topical or localised HRT such as vaginal tablets, creams, rings and pessaries which only supply oestrogen to the vaginal area without increasing the amount in the blood stream. However women with a personal or family history of oestrogen and progestogen-related cancers may need to avoid using any form of HRT. For women who can’t or don’t want to use HRT the FotonaSmooth laser treatment offers an alternative which may help to relieve some of their symptoms. It may also be a useful adjunct treatment for women using HRT and lubricants.

The FotonaSmooth uses a non-ablative ErYAG laser to produce thermal effects in the vaginal tissue which stimulates collagen remodelling and the synthesis of new collagen fibres, in effect shrinking and thickening the connective tissue in the vaginal wall. FotonaSmooth is non-invasive and the unique, patented robotic arm ensures the uniform and accurate treatment of the whole vagina.

(Q) Is there anything women can do to prevent vaginal atrophy or reduce its severity?

(A) Exercise is important for perimenopausal and post-menopausal women for many reasons but it can also help with vaginal atrophy as it helps to ensure good blood circulation to the pelvic region.

Maintaining regular sexual activity during peri and post menopause has also been shown to help maintain vaginal suppleness and the lubricative response, with sexually active women reporting fewer symptoms of atrophic vaginitis.

Some dietary modifications may be effective. Adding soy isoflavones (plant oestrogens), linseeds, fish oils, and black cohosh have been found to help some women

(Q) How do low dose topical hormone creams work and to what extent are they effective?

(A) Topical, low-dose vaginal oestrogens treatments help to improve the oestrogen levels in the vagina with little effect on the rest of the body. As they are applied locally much smaller doses are required than for general HRT medications such as pills and patches and the effects remain local with little or no oestrogen making it in to the blood stream. Some women find they help to improve elasticity and lubrication and can also help with some of the other symptoms such as urinary urgency and frequency, and help to reduce the need to urinate during the night. They may even help to improve urge incontinence a little but if a woman is suffering from stress urinary incontinence she will need supplementary treatment to address it.

While they are an effective treatment for most vaginal atrophy symptoms, such HRT treatments are usually prescribed for a wider range of post-menopausal conditions. If a patient has had breast or other oestrogen-related cancers or has some other existing conditions she may not be a suitable candidate for HRT. Some women on HRT experience side effects such as: bloating, breast tenderness or swelling, swelling in other parts of the body, nausea, leg cramps, headaches, indigestion and vaginal bleeding.

In the past some studies highlighted the potential risks of HRT and as a result, some women and doctors were reluctant to use it. But more recent studies have resulted in new guidelines that say the risks of HRT are small and are usually outweighed by the benefits so there is no need to for most women who are suffering distressing post-menopausal symptoms to avoid HRT. It is now generally considered safe and effective by doctors. Just to be safe patients on HRT should be monitored regularly for any possible side effects.

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