You may laugh at this title, but it is a question I am asked almost every day by my midlife patients. Menopausal changes begin to sneak up on us in our mid to late forties, for some even sooner, and in no time, we cross a threshold where our body changes in a way that feels utterly unfamiliar. These changes can be frightening for some and shocking for others, because in our youth obsessed society, we deny and resist the aging process, leaving us with little or no preparation or skill set to offer our body what it needs as it ages. When we live in denial, it is nearly impossible to prepare for what is coming and nourish ourselves at both physical and emotional levels so we can cross these thresholds with grace and vibrance.
Getting back to the vagina, vaginal dryness is a common symptom during the time before menopause (pre-menopause) and certainly after menopause when our menstrual cycles completely cease. Let me explain.
Menopause literally means, “a pause in menses”. This pause is permanent and lasts for the remainder of a woman’s life from that moment forward. Given that women are living longer, the years that a woman is menopausal can far outnumber the years she is menstrual. Menopause occurs when the ovaries stop producing reproductive hormones: estrogen, progesterone and testosterone. For some women the production ceases abruptly, for some, it is a gentler transition over time. All paths into menopause offer some of the same symptoms for most, the loss of libido, stiffer joints and ligaments, mental fog, emotional sensitivity, sleep disturbance, memory loss, dry skin and yes, vaginal dryness. Many of these symptoms occur due to a deficiency in progesterone and testosterone, but estradiol (estrogen) deficiency is the main culprit for vaginal dryness.
Estrogen encompasses three different types of estrogenic compounds produced in the body: estradiol, estrone and estriol. Estradiol is the estrogen that stimulates the growth of breast, uterine and vaginal tissue and causes the uterine wall to thicken during the first half of the menstrual cycle in preparation for pregnancy. As estradiol levels fall during menopause, estrone levels increase. Estrone is a weaker estrogen that is synthesized and stored in fat and can convert into estradiol. It is presumed to be a ‘bad’ estrogen when produced in high quantities in the body after menopause, increasing a woman’s risk of cancer. Estriol, however reaches its highest levels during pregnancy and is found to have a protective effect on the breast and uterine tissue and women with naturally higher estriol levels have in fact been shown to have lower rates of breast cancer.
Many parts of a woman’s body have receptors for reproductive hormones — the breasts, brain, nervous system, muscles, and the uterine and vaginal walls, to name a few. These are the most effected during and after menopause as estradiol receptors which were once occupied with estradiol, now, lay empty. Estradiol (estrogen) which once bonded to the receptors in the breast, uterine and vaginal tissue, is no longer produced by the ovaries so the tissues that are estrogen dependent begin to atrophy and dry out and moisture and lubrication begins to wane. Over time, the receptors themselves go through a process called ‘down-regulation’, reducing the numbers and functionality of the receptors. The body has evolved to be efficient so it eliminates or dials down what is no longer required, particularly when hormone levels drop. Women may notice pain during sexual intercourse due to the dryness of the vaginal wall and some may even bleed due to the effect of friction on dry tissues. For many, who are unprepared for these changes, they are startled by them and feel that something is wrong.
The drying out of the vaginal wall is a normal part of the process of transitioning from a reproductive state to a non-reproductive one, when estradiol levels fall to negligible levels.
Pre and post-menopausal women have many choices for synthetic hormonal insertions offered by conventional medicine for vaginal lubrication, including Hormone Replacement Therapy or HRT, none of which I would recommend due to their side effect profiles which include breast cancer, heart attacks, strokes and blood clots. I have seen women in my office whose physicians commonly prescribe an E-string — a vaginal estradiol for atrophy. These women develop frighteningly high blood estrogen levels, too dangerous for a post-menopausal body whose receptors are down-regulated and unable to process high levels of estrogen. Post-menopausal estrogen/estradiol elevations are responsible for the dangerous side effects of high dose natural and synthetic estradiol.
A much better and safer alternative to Estradiol is Estriol. Estriol is a much safer form of estrogen as described above, which when inserted into the vagina as a cream or a suppository has a profoundly positive effect on lubrication by stimulating the cells that line the vagina to create more moisture. Given its protective effects in a woman’s body, this is a very safe alternative to the high risk, estrogen compounds prescribed in conventional medicine, and has nearly no side effects. In fact, it may be protective against some of the dangerous side effects of estradiol on a post-menopausal woman’s body.
Estriol can only be prescribed by a physician skilled in compounded hormones. For my patients, it has been a life-saver and in many cases has also restored women’s libidos which are impacted not just by a reduction in female hormones, but also by anticipated pain during intercourse.
Other options for counteracting vaginal dryness are water based lubricants that can be helpful for symptomatic relief. These do not moisturize the vaginal wall, they just provide lubrication and potential tearing and sloughing of the atrophied tissue. If you choose to use a vaginal lubricant, please use only a water based one with no chemicals or petroleum based ingredients or fragrances, as the vaginal wall will absorb any compounds or chemicals inserted, directly into your bloodstream.
A powerful way to help your body retain moisture and regenerate cells of course is a Whole Food Plant Based Diet accompanied by at least 54 to 64 oz of water per day. A plant based diet is the best regenerator of cells after menopause and people who practice this lifestyle live longer and age more slowly as cell regeneration is maximized. Water of course, a natural detoxifier and lubricant, is essential for healthy cells and a healthy body. It is the best source of hydration at any age and can potentiate vaginal lubrication alongside other safe methods of lubrication mentioned above.
I hope this has provided you with some basic knowledge of what causes vaginal dryness before, during and after menopause. It is so important for you to learn about how hormones affect your body and what happens when they wane. It is especially important for you to know what the safe available alternatives are, so you are not talked into high dose synthetic or natural hormone therapy that can leave you with irreversible and damaging side effects.