Vaginal Atrophy

To treat genitourinary syndrome of menopause, your healthcare professional might recommend that you first try a remedy you can buy without a prescription. If that doesn’t help ease your symptoms, you may opt for a hormone treatment, other prescription medicine or a device to stimulate and stretch vaginal tissues, called a vaginal dilator.

Vaginal moisturizers or lubricants

As a first step, you might try one of these products to ease symptoms:

• Vaginal moisturizers. These products (K-Y Liquibeads, Replens, Sliquid, others) can help restore some moisture to your vagina. You may have to use the moisturizer every few days. Its effects tend to last a bit longer than those of a lubricant.
• Water- or silicone-based lubricants. You can use water-based (Astroglide, K-Y Jelly, Sliquid, others) or silicone-based lubricants (ID Millennium, Pink, Pjur, others) just before sex to ease pain and friction. Choose lubricants that don’t contain glycerin or warming ingredients such as capsaicin. Your vagina may get irritated if you’re sensitive to these. Stay away from petroleum jelly or other oil-based products for lubrication if you’re also using condoms. These can break down latex condoms on contact.

Topical estrogen

This is also called vaginal estrogen. It’s a lab-made version of the hormone that goes directly into the tissues of the vagina. Compared to estrogen taken by mouth, vaginal estrogen works at lower doses and limits your overall exposure to estrogen. That’s because less of the hormone reaches the bloodstream. It also may provide better direct relief of symptoms.

Vaginal estrogen therapy comes in various forms. Because they all seem to work equally well, you and your healthcare professional can decide which one is best for you.

• Vaginal estrogen cream (Estrace, Premarin). You insert this cream into your vagina with a device called an applicator, usually at bedtime. Most often, you use it daily for 1 to 3 weeks, and then 1 to 3 times a week after that. But ask your healthcare professional how much cream to use and how often to insert it.
• Vaginal estrogen suppositories (Imvexxy). You place these low-dose estrogen treatments about 2 inches into the vagina daily for two weeks. After that, you insert them twice a week.
• Vaginal estrogen ring (Estring). You or your healthcare professional inserts a soft, flexible ring into the upper part of the vagina. The ring releases a steady dose of estrogen. It needs to be replaced about every three months. Many people like the convenience this offers. A different, higher-dose ring called Femring is considered a system-wide treatment rather than a topical one.
• Vaginal estrogen tablet (Vagifem, Yuvafem). You use an applicator to place this treatment in your vagina. Ask your healthcare professional how often to insert the tablet. For instance, you might use it daily for the first two weeks, and then twice a week after that.

Ospemifene (Osphena)

Taken daily, this pill can help relieve painful sex symptoms in those with moderate to severe GSM. Ospemifene is an option for women who have had a history of estrogen-dependent breast cancer.

Prasterone (Intrarosa)

These vaginal inserts deliver the hormone DHEA directly to the vagina to help ease painful sex. DHEA is a hormone that helps the body make other hormones, including estrogen. Prasterone is used nightly for moderate to severe vaginal atrophy.

Systemic estrogen therapy

Sometimes, vaginal dryness is linked with other symptoms of menopause, such as moderate or severe hot flashes. If you have all of these symptoms, your healthcare professional may recommend estrogen pills, patches or gel, or a higher-dose estrogen ring. Estrogen taken by mouth, or as a patch or gel onto the skin, enters your entire system. Ask your healthcare professional to talk with you about the risks and benefits of systemic estrogen. If you still have your uterus, you will need another hormone called progestin along with estrogen.

Vaginal dilators

These devices stimulate and stretch the vaginal tissues and underlying muscles to reverse narrowing of the vagina. You can use them along with estrogen therapy.

If painful sex is a concern, vaginal dilators may relieve discomfort by stretching the vagina. You can buy them without a prescription. But if your symptoms are very painful, pelvic floor physical therapy also may help. Your provider or a pelvic physical therapist can teach you how to use dilators.

Topical lidocaine

This prescription ointment or gel can ease pain from sex. You put it on the opening of the vagina 5 to 10 minutes before sex.

If you’ve had breast cancer

If you have a history of breast cancer, tell your healthcare professional and think about these options:

• Nonhormonal treatments. Try moisturizers and lubricants as a first choice.
• Vaginal dilators. These devices stimulate and stretch the tissues and muscles of the vagina. They don’t add hormones to the body.
• Vaginal estrogen. Your cancer specialist, called an oncologist, can talk with your main healthcare professional about whether low-dose vaginal estrogen might help you. It may be an option if hormone-free treatments — such as moisturizes, lubricants and dilators — don’t ease your symptoms. For most women, there’s minimal risk with low-dose estrogen of breast cancer coming back.
• Systemic estrogen therapy. Systemic estrogen treatment generally isn’t recommended, especially if your breast cancer was sensitive to hormones.