Normally the walls lining the vagina are kept lubricated by fluid that is produced by glands in the cervix. This lubrication provides protection to the female reproductive organs and makes intercource more comfortable. In fact, during times of arousal, more vaginal secretions are produced, which prevent ulceration and fissures that can be very painful. In cases of vaginal dryness, even gentle friction during intercourse can be very painful. Vaginal secretions keep the vagina supple and moist. They are slightly acidic (pH3.5-4.5), which also reduces the risk of infection.
Many women experience periods of vaginal dryness, which can be accompanied by itching and soreness. As well as discomfort during intercourse, vaginal dryness can cause pain during urination. It can cause discomfort when sitting, standing or exercising, having a profound impact on a female’s quality of life. Yet, despite this, it is a problem women are unwilling to discuss, so it often goes undiagnosed and untreated.
The menopause is a major contributor to vaginal dryness, with over half of women aged 50 and older, experiencing some degree of dryness. However, up to 17% of younger women who are premenopausal, will experience vaginal dryness as well. Some of the most common reasons for vaginal dryness are explored below.
Most women start to experience menopausal symptoms between the ages of 45 and 55. The ovaries stop producing oestradiol and start producing the less potent oestrone. Some of the most common symptoms of menopause are hot flushes, night sweats and vaginal issues. With reduced oestrogen, the vagina starts to show signs of atrophy; the epithelial lining thins, there is a loss of elasticity, meaning that the vagina becomes shorter and narrower, and blood supply reduces as vascularisation to the vulvovaginal region is lost. The pH of the vagina increases, becoming slightly more alkaline and, thus, less capable of fighting infection, meaning women are more susceptible to urinary tract infections. The resulting physiological symptoms are dryness, irritation, itching and pain during sex (dyspareunia) and urination (dysuria). Together, these symptoms are termed the genitourinary syndrome of menopause (GSM).
The most common consequence of GSM is vaginal dryness, affecting between 55% and 75% of postmenopausal women. Unlike other menopausal symptoms, which diminish over time, those affecting the vagina are chronic and progressive, meaning that the sooner women seek help, the better.
Non-hormonal treatments, such as moisturisers and lubricants, do provide relief from mild symptoms of GSM; however, they do not reverse the signs of atrophy and their effectiveness is limited. As a long-term solution, they are probably not ideal. The most effective treatment option for most women experiencing moderate-severe GSM is the application of topical, localised oestrogen. This can be in the form of cream, vaginal rings or pessaries, which are all applied directly to the affected area. This limits systemic oestrogen exposure, which is beneficial as an excess of this hormone can cause cellular proliferation and increase the risk of reproductive tract cancers. Approximately 90% of women who use a topical oestrogen report improved symptoms. Alternative treatment options include selective oestrogen receptor modulators, which improve the structure and pH of the vagina, and laser therapies. Laser therapy shows potential as a viable treatment option, improving vascularity and increasing the thickness of the vagina eptithelium. However, longer-term studies are needed to explore the effectiveness of this approach over time.
2. Cancer treatment
Chemotherapy can bring about menopausal-like symptoms if there is a sudden loss of oestrogen production. This can happen with those drugs designed to block hormone production, which are given to women whose tumours are hormonally driven. Whilst this can be very effective at preventing tumour growth, the nature of the treatment means that there is an abrupt change in hormone levels, causing symptoms that are more intense than those experienced during a normal menopause. In most cases, normal hormonal activity will recommence once treatment is finished; however, the difficulty comes from providing symptomatic relief whilst treatment is ongoing. Hormonally sensitive cancers are generally incompatible with oestrogen therapy, which, as described above, is often the treatment of choice for women going through a standard menopause. Moisturisers and lubricants are likely to be the best option for women experiencing vaginal dryness as a consequence of their cancer treatment.
Women with early stage breast cancer are often treated with aromatase inhibitors; however, 74% of patients report reduced vaginal lubrication during treatment and a concurrent decreased libido. These symptoms negatively impact quality of life and can lead to low compliance. Testosterone cream has been shown to improve symptoms of vaginal atrophy in women taking aromatase inhibitors.
Women who undergo radiotherapy to the pelvic area are also at increased risk of vaginal dryness. If the ovaries are targeted they may stop producing oestrogen, causing an immediate menopause, with all of its associated symptoms. If the vagina or vulva are targeted specifically, their linings can become irritated, inflamed and tender. The extent and permanence of these issues depends on how stringent the treatment regime is.
3. Hysterectomy (oophorectomy)
When the ovaries are removed during a hysterectomy, known as an oophorectomy, a surgical menopause is induced. Hysterectomies are performed for a variety of reasons; they can be used as a preventative measure for women at high risk of future malignancies, as well as a means of easing chronic, painful heavy periods. Women with severe endometriosis might opt for a hysterectomy, if they cannot control their symptoms through other methods. A hysterectomy is not a decision to be taken lightly, as it does render a female irreversibly infertile.
Even those women who do not have their ovaries removed during their hysterectomy are likely to experience a reduction in circulating hormones. Less oestrogen will lead to reduced vaginal lubrication and a thinner, more fragile vaginal lining. These will both contribute to the sensation of vaginal dryness.
A surgical menopause brings with it many of the symptoms of a normal physiological menopause, including GSM and vaginal dryness. Oestrogen withdrawal is immediate and abrupt and, as such, symptoms can be more intense than those experienced during a normal menopause. Hormonal therapy can be used, provided the woman is not at increased risk of developing other hormonally-sensitive carcinomas.
The most common sexual health issue in females with diabetes is reported to be vaginal dryness. It is thought that high blood sugar levels cause damage to the blood vessels and nerves that supply the vagina, resulting in a lack of lubrication. In fact, 60-70% of people with diabetes experience nerve damage. Nerve damage can contribute to sexual dysfunction by diminishing the normal response to sexual stimuli; one consequence of this being reduced vaginal lubrication. Reduced blood flow to the vagina can also cause a loss of sensation, making arousal difficult. Whilst the mechanisms remain to be fully elucidated, another theory for the reduced vaginal secretions in females with diabetes is an imbalance in hormone levels across the body. As described in detail above, oestrogen deficiencies can have a significant impact on the health of the vagina.
It is already well established that diabetes can have a negative effect on a male’s sexual health, having a particularly strong association with erectile dysfunction. However, the impact of the condition on a female’s sexual behaviour and reproductive system was less well defined. A long-term epidemiological study of males and females with diabetes type I, went some way to identifying the extent of the problem, when it demonstrated that 35% of females reported sexual dysfunction, and of these almost half (47%) had lubrication issues.
The first line approach for resolving any diabetes-related symptoms is to attempt to keep blood sugar levels under control. If this is successful, any associated symptoms should be minimised. The use of vaginal lubricants and moisturisers may also be recommended.
5. Sjögren’s syndrome
Sjögren’s syndrome is an autoimmune disease affecting the moisture-producing exocrine glands throughout the body. The exact aetiology is unknown and it is most frequently diagnosed when patients present with lacrimal and salivary gland dysfunction, causing dry eyes and a dry mouth respectively. As well as affecting the eyes and mouth, the condition can also cause problems with the thyroid gland, the lungs, the gastrointestinal system, the skin and the genital tract. The most common genitalia abnormality is reduced vaginal secretions, which manifests as chronic dyspareunia.
There are no vaginal glands for Sjögren’s to act on directly, but women with the condition often have an altered vaginal epithelium, inflammatory changes in the vagina and chronic cervicitis (inflammation of the cervix). These factors, either alone, or in combination, contribute to the vaginal dryness experienced by women with Sjögren’s syndrome.
Women are ten times more likely to develop Sjögren’s syndrome than men, and symptoms usually start when a person is in their 40s or 50s. For this reason, the condition often gets misdiagnosed as menopause. As the condition can affect various exocrine glands, treatment is symptom-dependent. Women who have vaginal dryness can try moisturisers, lubricants and localised oestrogen therapy. They may, however, need other medications to treat their other symptoms.
In addition to these major conditions, transient lifestyle factors can also affect the production of vaginal secretions. Women who are breastfeeding may experience vaginal dryness as their body enters a state of hyperprolactinemia, which causes a reduction in oestrogen levels. Certain medications, including cold and flu remedies, can dry out mucous membranes, reducing secretions throughout the body. The use of strongly perfumed soaps and hygiene products can also be detrimental to the status quo of the vagina.
Women who experience vaginal dryness should also be encouraged to adopt lifestyle changes, such as reducing stress and stopping smoking, as these can both exacerbate the condition. Regular intercourse can also improve blood circulation.
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