Treatments For Vaginal Dryness

by Marcelle Pick, OB-GYN NP

If you are like many women we see in our clinic and you suffer from vaginal dryness, we have words of hope for you. You can find relief without taking large amounts of estrogen into your system. Locally applied bioidentical estrogens are considered a much safer option than oral hormone therapy since most of them allow only minimal amounts of estrogen to enter into your circulation.

We encourage you to be evaluated by your gynecologist to make sure there is no underlying cause for your vaginal dryness; and it’s important to follow up to make sure your condition improves. We want you to know, however, that the first step most practitioners will take in treating vaginal dryness will include a prescription for Premarin Vaginal Cream. This product contains estrogens from female horses, which are unnatural to our bodies and often much too strong. It’s nice to know there are several safe and effective bioidentical choices for treating vaginal dryness. The greatest news of all is that the creams are just as effective – in fact, probably more so.

The three key estrogens are estrone (E1), estradiol (E2), and estriol (E3). Presently pharmaceutical companies produce estradiol-based bioidentical vaginal products. You should have as much information as possible so that you know which ones to request. The charts that are below list the vaginal dryness treatments we most commonly prescribe at the Women to Women Clinic. We’ve also listed some nonprescription choices to use in addition to bioidentical estrogen, or on their own, to help to soothe inflamed vaginal tissues.

Menopause Nutritional Supplement

PRESCRIPTION ESTROGEN PRODUCTS* for VAGINAL DRYNESS

Estriol vaginal cream

ContentsWomen to Women health care clinic patients are prescribed estriol vaginal cream, as a first stage of intervention. It is formulated in a pH-balanced base in concentrations of 0.6 mg/g or 0.8 mg/g.  Sometimes the dose is higher if the atrophy is severe.
Typical useOne gram is inserted vaginally at bedtime every night for 7-10 nights, then 2-3 times weekly on-going. A small amount of the cream can be applied to the vulva and external areas of the vagina as needed.
ProsEstriol vaginal cream is a great option for vaginal dryness, because it is so gentle and  safe to use, especially if there are concerns related to breast cancer. Many of the local oncologists are now using estriol for women that have a history or have present disease. This type of cream will slowly but effectively help both internal and external vaginal tissue, and can also be used on the vulva and urethral tissue. Results may be expected in as little as 1-2 weeks.Estriol vaginal cream can also be custom-compounded to include a small amount of testosterone and DHEA. This is especially beneficial for many women as it quickly plumps up the tissue and can also increase sex drive.
ConsSome women report the cream feels messy. In order for this to remain an effective method, you need to use it as recommended. It is not intended for use as a personal lubricant for sexual intercourse.  The best time to use this is at night before bed. Some women also have some burning when they first introduce the cream, but changing the base can alleviate this symptom.
AvailabilityEstriol vaginal cream is available only by prescription from your provider. Many compounding pharmacies are able to formulate this and it is almost always very affordable.  Many insurance companies do not pay for this product.

Vagifem vaginal inserts

ContentsThe Vagifem estradiol vaginal tablets are little, white suppositories containing 10.3 mcg of 17ß-estradiol hemihydrate, which is equivalent to 10 mcg of estradiol. They come in boxes of 8 or 18 tabs. Each box comes with an applicator.
Typical useOne suppository is used vaginally at bedtime anywhere from 7–14 nights, and then reduced to one insert two to three nights per week for maintenance.
ProsThese inserts are not messy, they are easy to use and it is very effective for renewing the vaginal tissues. With a little time, the vulva also usually responds.
ConsVagifem usually does not work as quickly as creams do to the external tissues. You have to use it regularly to maintain results. For women with severe atrophy a cream may be necessary to use initially and then the suppositories can be used. It is not intended for use as a lubricant prior to sexual intercourse.
AvailabilityThis brand name product is available by prescription through regular pharmacies.

Estrace vaginal cream

ContentsEstradiol vaginal cream, USP, 0.01%
Typical useOne gram is applied vaginally at bedtime for approximately 7-10 nights, and then should be reduced to 1–3 times per week for long-term care. Massaging small amounts to the vulva and inner labia can also be very helpful.  This recommendation is seldom mentioned on the insert directions.
ProsResults are often noted in 1–2 weeks, but it may take longer for optimal results. Using this product can be very helpful for those with extreme atrophy prior to using the Vagifem or 90 day ring products.
ConsWomen often complain that it can feel messy, especially the first days of use. You should keep in mind that you need to keep with the routine to maintain results.  It also should not be used prior to sex as it is a hormone. A burning sensation has been reported, therefore you may want to consider duplicating the cream with a compounding pharmacy in a more hypoallergenic, pH-balanced base to help with the comfort.
AvailabilityThis brand name product is available by prescription through regular pharmacies.

Estring 90-day vaginal ring

ContentsEstring (estradiol vaginal ring) is a silicone-based ring containing 2 mg estradiol. Estring releases estradiol (approximately 7.5 mcg/24 hours) in a consistent stable manner over 90 days.
Typical useOne ring is inserted into the vagina and stays in place for 90 days. After 90 days, it is replaced with new ring.
ProsThis delivers a low dose of estradiol for 90 days of use with no modifications needed. It can help to provide support to the walls of the vagina in women whose pelvic floor muscles have weakened or are weak.
ConsThis device does require some amount of skill to insert and take out. Certain women have had discomfort with the insertion and removal process and opt to visit with their practitioner every 90 days to have it done for them. Many women find an Estring comfortable; while others do not like the way it feels and complain that it is uncomfortable. The use of Estrace vaginal cream for one month prior to initial insertion of an Estring can greatly improve the comfort level. Occasionally some women complain of breast tenderness with the estring – if this happens you may be getting too much estrogen that is actually getting systemically absorbed. This product has also been known to exacerbate endometriosis if it is present.
AvailabilityThis brand name product is available by prescription through regular pharmacies.

Femring 90-day vaginal ring

ContentsFemring (estradiol acetate) is a flexible silicone-based ring which contains time-released estradiol acetate. It is available in two strengths: 0.05 mg/day and 0.10 mg/day. The 0.10 mg/day usually requires special ordering. Both of these strengths issue estradiol acetate daily for 3 months and supply system-wide, not just vaginal-specific estrogen replacement therapy. This is quite different in its applicability as it is a type of Hormone Replacement Therapy which also provides estrogen locally and systemically.
Typical useA ring is placed into the vagina for 90 days and then removed and replaced as needed.
ProsThe Femring is softer and is more flexible than the Estring, so insertion and removal is reported as easier for many women. It can help to support the walls of the vagina for women whose pelvic floor muscles are weak.
ConsSome women aren’t comfortable inserting and removing the device, so they may require a visit to their provider every 90 days to have it changed. Some women are not comfortable wearing this particular type of device. This product has a potential for causing exacerbation of endometriosis discomfort in women with a history of this due to the potent delivery of estrogen directly within the pelvic area.
NoteThe product provides estradiol vaginally, as well as systemically,  similar to the estradiol patch or other forms of Hormone Replacement Therapy, to treat vasomotor (for example hot flashes) as well as vaginal symptoms. This is not just a localized vaginal treatment, but is a hormone replacement treatment for system wide therapy. If you still have your uterus, you must use a prescription-strength progesterone (bioidentical) product, like Prometrium, with this product.
AvailabilityThis brand name product is available by prescription through regular pharmacies.
* Note: Brand name pharmaceuticals are all FDA-approved and regulated.  These products are packaged with the same warnings that the FDA states must be listed on all estrogen products. There is evidence to suggest that taking low-doses of estradiol either through topical means or vaginally does not increase the risk for blood clots to the degree that taking estrogen by mouth does.  However, the FDA continues to require the warning label on all estrogen products.

Treatment choices for vaginal dryness

This chart can help you understand the choices that are available. When you are speaking with your practitioner about topical bioidentical estrogen, it may help to have a little more information.

Non hormonal products for vaginal dryness

There are many non hormonal treatments that we can look at to help soothe vaginal dryness. Non-prescription products for vaginal dryness can be used as needed. They may be used in-between or in addition to the prescription bioidentical estrogen. Some women feel very discouraged – they have tried everything and have found no relief. Another similar case is a breast cancer patient who does not wish to risk using vaginal estrogen. For both of these women, we recommend manual massage with some sort of lubricant.

Always be sure to read the labels on the products you are considering to use and make sure to choose ones that contain no harsh chemical ingredients, preservative, petro chemicals, endocrine disruptors or other irritants. It’s best to avoid alcohol, parabens and propylene glycol. In the chart below we’ve listed a few products which have been used by many women and usually have a great results.

OVER-THE-COUNTER PRODUCTS for VAGINAL DRYNESS

Vitamin E vaginal suppositories

These are excellent for women who are not using a prescription products or on the night you do not use the vaginal estrogen product.  (Be sure to only choose a natural-source vitamin E products).

Natural oils

Grapeseed, olive, sweet almond, sunflower, or coconut are great natural oils that are gentle during or after bathing and even with sexual intercourse.

Sylk

Sylk is a natural personal lubricant which is a wonderful alternative that numerous women prefer. This natural lubricant is made from the kiwifruit vine, Sylk contains no parabens or propylene glycol. It tends to be less sticky than other lubricants.

Astroglide

Astroglide is a lubricant which is beneficial for providing more lubrication when the area tends to be drier and more friction is experienced. This then helps to decrease discomfort with intercourse by decreasing the friction. You can find it in glycerin-free and also paraben-free for those that are concerned.

At Women to Women, we know that each woman is different and unique in her response to vaginal bioidentical estrogen and other products. Please understand that you may need to try several before your vaginal dryness resolves. Be patient with yourself, and with your body, and never give up hope. You always have options, whether you have mild or severe, occasional or on-going vaginal dryness. We want you to know your alternatives. Some women find that improving their diet and using a personal lubricant alleviates their vaginal dryness; other women may need to use stronger treatments. Try the above options, and if one or two don’t help you find relief from your vaginal dryness, try to stay hopeful and receptive to trying another approach until you’re successful.