Use It or Lose It? What We Don’t Know about Keeping the Vagina Healthy

Perhaps the most common sexual problem after cancer treatment for women is vaginal dryness and pain. Even among healthy women, over half experience these symptoms after they go through menopause. Without estrogen, the vagina loses some of its blood supply. Spongy tissues in the vulva and vaginal walls thin and are less able to stretch. This process is called vaginal atrophy. Normally, when a woman gets sexually aroused, blood rushes into the whole genital area. The vagina becomes deeper and wider, and its special lining oozes a clear, slippery fluid. These changes make intercourse pleasurable, rather than uncomfortable or downright painful. The clitoris and the inner and outer lips of the vulva also fill with blood and swell. Think of it as a kind of female, “internal erection.”

Cancer treatments in younger women sometimes lead to an abrupt menopause or premature ovarian failure. Vaginal dryness and pain during sex seem to be more severe when hormone changes occur suddenly. To make things worse, any radiation therapy to the pelvis directly damages the delicate tissues of the vagina and vulva, sometimes creating tight scar tissue or ulcers that are very slow to heal. Surgery that removes organs in the pelvis, including the rectum, bladder, or uterus and cervix, also can lead to scarring that adds to problems with pain during sex. Women who take aromatase inhibitors as part of treatment for breast cancer also have severe vaginal atrophy because their estrogen levels are nearly zero. Pain with sex can often be minimized  by using nonhormonal moisturizers and lubricants, learning to control pelvic floor muscles, using vaginal dilators, and if it is not too risky from a cancer standpoint, using low dose vaginal estrogens. A new drug, ospemifene (Osphena), also treats vaginal atrophy and may even have some ability to prevent breast cancer (see previous post,

What bothers me is our limited knowledge of factors that increase a woman’s risk for vaginal atrophy and for having pain during sex. In a study of 182 women who had pain with sex after menopause, Dr. Irv Binik and his research group in Canada found that the women’s levels of estrone, estradiol, and progesterone (the hormones made by the ovaries) did not predict the severity of their pain. A physical measure of atrophy in the vagina was linked to pain, but women who had worse pain were also more depressed and anxious, were less satisfied with their relationships, and were more likely to “catastrophize” when they noted pain.* We do not know what is the chicken and what is the egg here, but clearly the state of a woman’s vulva and vagina is just one factor. How she copes with pain, and with life in general, also plays a role in having pain during sex. Although replacing a woman’s estrogen with pills, patches, or vaginal creams/rings/tablets clearly helps with vaginal dryness, a number of studies have found it does not completely restore women to having pain-free sex.

Maybe once the vagina and vulva have atrophied, some of the damage is permanent? In a study of over 27,000 women aged 50 to 79, those who had not had sex in the past year had worse vaginal atrophy.** Is the old adage, “Use it or lose it” correct? Or is it just that women with vaginal dryness and pain learn to avoid sex?

There is a scientific reason why having sex regularly may prevent some of the atrophy after menopause. The blood vessels and tissue inside of the vulva and vaginal walls is fairly similar to the “erectile tissue” inside of the penis. Spongy tissue made up of muscle cells and many tiny blood vessels relaxes with sexual excitement, allowing more blood to flow in. Chemical changes inside the tissue involve many of the same “neurotransmitters” in men and women—i.e. the same types of chemical messengers control the physical events of sexual excitement. In men, researchers believe that going through a period without getting frequent, firm erections can damage this special tissue. In fact it atrophies, just like the vagina and vulva do with menopause. The penis shrinks in size, and since the erectile tissue cannot expand smoothly to let blood flow in, a man permanently loses his ability to get and keep firm erections without medical treatments. After cancer surgeries, like radical prostatectomy or radical cystectomy, men are advised to try “penile rehabilitation.” They use oral medicines or give themselves injections in the side of the penis to provoke erections. The hope is that getting fresh blood loaded with oxygen into the erectile tissue can keep it healthy and prevent atrophy. Physically stretching the tissue also may be important. Atrophy of the penis is less of a problem in men who use a “vacuum erection device” (or VED) frequently. The VED is a pump that creates a vacuum around the outside of the penis, drawing blood into the erectile tissue, which expands to its fullest size. The jury is still out on whether penile rehabilitation helps men to recover erections more fully after cancer surgery, but research on animals shows clear benefits. Unfortunately, it is hard to get men to stick with the routine of penile rehabilitation long enough for it to work!

A number of years ago, some sex researchers invented a similar vacuum pump to put over the clitoris, called the Eros.™ It is no longer on the market. Although some wild claims were made about its benefits from some very small studies, pumping up the clitoris would not necessarily increase blood flow to the walls of the vagina or the tissues in the rest of the vulva. A similar product that claims to get women in the mood for sex is the Fiera, a vibrator that also adds suction on the vulva (and even allows a partner to start the process remotely via a smartphone app). Although these high tech options sound innovative, it is probable that the best way to increase blood flow to all the right parts in a woman is to get sexually excited–no matter whether that happens with a partner, by self-touch, or by sexual fantasy. Vaginal dilators, cylinders made of smooth silicone, can be used to stretch out the vagina physically, but it is very difficult to get women to use a dilator regularly. If “vaginal rehabilitation” is going to work, it is probably important to either have sex with some kind of vaginal penetration or to use a dilator at least 2-3 times a week. Women are busy, and even with vaginal moisturizers and lubricants, sometimes penetration hurts. The other issue is that vaginal rehabilitation needs to be PREVENTIVE. Common sense suggests it would be important to start stretching the vagina and getting sexually aroused to increase blood flow to the tissues before atrophy gets severe. My research team at MD Anderson did a study with women to see if we could prevent some of the problems of pain with sex in women using an aromatase inhibitor for hormone therapy after cancer. We are starting women on vaginal moisturizers, lubricants, and dilators within the first 4 weeks of their hormone treatment. The treatment combination appeared promising, although we only studied a small group of women and did not directly measure the physical and chemical changes in the vagina.

Research gets funded when pharma companies sense a profit. That is why we know so much about men’s erections. With the aging of our population, and greater interest among today’s women in staying sexually active as they get older, some companies are trying to make vaginal atrophy “the new ED.” However, they are focusing very simplistically on getting women to use some type of estrogen or perhaps drugs like ospemifene or lasofoxifene that mimic the action of estrogen without all the risks. Worse, they are pushing ineffective and dangerous testosterone replacement. I do not see anyone studying the basic reasons why some women get more vaginal atrophy than others. Is it because they stop having sex, or because they have damaged blood vessels related to diabetes or high blood pressure? Until we have a better understanding of our bodies, our ability to find the most effective and least risky way to treat vaginal atrophy will also lag way behind the treatments available for men.

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.

*Kao A, Binik YM, Amsel R, et al. Biophsychosocial predictors of postmenopausal dyspareunia: the role of steroid hormones, vulvovaginal atrophy, cognitive-emotional factors, and dyadic adjustment. Journal of Sexual Medicine 2012;9:2066-76.

**Gass MLS, Cochrane BB, Larson JC, et al. Patterns and predictors of sexual activity among women in the hormone therapy trials of the Women’s Health Initiative. Menopause 2011;11:1160-71.

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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