A New Vaginal Hormone Treatment for Dryness and Pain with Sex

At least half of women notice vaginal dryness in the years after reaching menopause, but very few seek medical help. Without the estrogen hormone that circulates in women's bloodstreams before menopause, the vagina produces less natural lubrication with sexual excitement. It also tends to shrink in size and loses some of its ability to stretch during sexual excitement. Vaginal dryness and pain is even more common among women treated for cancer, since the hormone changes at menopause are often more sudden and severe.

Many women can prevent actual pain during sexual caressing and penetration by using over-the-counter vaginal moisturizers (gels put in the vagina at bedtime) or lubricants (slippery fluids that are water-based or silicone-based) used during sex. However, some women still have dryness and pain. One option is to use low-dose estrogen from a vaginal ring or a vaginal tablet that melts. The estrogen helps restore the vagina to a more "youthful" state. However, some estrogen gets into the blood circulating in a woman's body by being absorbed through the mucous membrane that lines her vagina. Although the estrogen levels in the blood usually remain below the threshold that is normal during menopause, a few women end up with higher values. The concern is that 1 in 8 women in the United States has had or will have breast cancer. Higher levels of estrogen after menopause can be a risk factor to trigger a new breast cancer, or to increase the chances that a previous breast cancer will return.

Women have been caught between the old rock and a hard place, wanting to be able to enjoy sex, but also fearing that using vaginal estrogen could increase their risk of breast (or less commonly, uterine or ovarian) cancer. A new vaginal prescription drug, Intrarosa (generic name, prasterone), may be a safer option for some women. Like many vaginal moisturizers or estrogen tablets, Intrarosa is an oval-shaped suppository that a woman puts into her vagina at bedtime, using an applicator. It melts, supplying a hormone called dehydroepiandrosterone (DHEA) to the vaginal lining. DHEA is a weak cousin to testosterone (often called the male sex hormone, but actually also made in women's bodies). According to the researchers who developed Intrarosa, when used nightly it was more effective than a similar suppository without the active ingredient, in improving vaginal dryness and pain during sex. Partners confirmed the improvement, but it is important that only about a third of partners said the vaginal dryness problem was gone. The main side effects of Intrarosa were too much vaginal discharge and some abnormal pap smear results. Less than 10% of women complained that they had too much vaginal discharge after using Intrarosa. Research on medications in general also shows that many people do not use a prescription daily, because they forget or get tired of the hassle. 

So Intrarosa seems to be about as effective (or maybe a little less) than using ultra low-dose vaginal estrogen. It needs to be used more often than vaginal estrogen, which is less convenient. It has some advantages, however. After using Intrarosa as directed, women still had levels of estrogen and testosterone hormones in their blood that were below the threshold for women past menopause. In other words, this drug helps restore the vaginal lining with less risk of increasing the body's levels of hormones that could increase cancer risk. The researchers also believe that Intrarosa may help women experience more pleasure with sex because nerves in the vagina are sensitive to DHEA. 

Although the Food and Drug Administration (FDA) has approved Intrarosa as a prescription drug to treat moderate to severe vaginal dryness and menopausal changes, it still includes a warning that women who have had breast cancer should not use it. All the research thus far has been funded by the company that will sell Intrarosa. It will be helpful to have some independent studies to confirm that Intrarosa does not increase hormone levels that could affect a woman's risk of a new or return breast cancer.

This educational material is intended for informational purposes only and is not intended to replace, or substitute for, professional advice, counseling, diagnosis, or treatment. Always seek the advice of a qualified health provider with any questions you may have regarding a condition. Never disregard professional advice or delay in seeking treatment because of something you have read in this educational material.

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