Our Bodies, Ourselves (111 page)

Some prescription and over-the-counter drugs may cause or contribute to vaginal dryness. Antihistamines, for example, dry vaginal tissue as well as nose and eye tissues. Douches, sprays, and colored or perfumed toilet paper and soaps can irritate vaginal and vulvar tissues. There are also a variety of skin conditions that can cause pain and/or irritation with insertive sex. Consult a clinician if this is a persistent problem for you. (See
“Painful Intercourse/Penetration.”
)

The following tips can relieve vaginal dryness and resulting discomfort with sex:

Lubricants and vaginal moisturizers
, such as Silk-E, Albolene, Astroglide, or Slippery Stuff may be helpful during sex. Vegetable oil is another option. For more information, see
“Lubrication.”
If dryness persists, try an over-the-counter moisturizer, such as Replens, which may be used one or more times a week but
not
at the time of penetration. Avoid scratching, which can irritate delicate tissues and lead to infections and further problems. Itching can be a sign of a yeast or fungal infection
that needs treatment
. Applying prescription steroid ointment to the pubic and vaginal area can relieve itching.

Regular sexual activity
also helps maintain vaginal flexibility and pliability, presumably because it increases blood supply to the vagina and can have a stretching effect.

Wait until you are fully aroused before penetration
. Vaginal dryness during sexual activity at any age may simply mean that you need more stimulation and maybe even an orgasm before penetration. You may want to tell your sex partner(s) that you will need lots of varied stimulation and experimentation to find out what is arousing.

Drink more liquids
—some recommend eight or more cups each day.

Graduated dilators
may be used to gently expand your vaginal walls and increase elasticity. Start with a small size, and work your way up. As a sixty-year-old woman puts it, “Ah, the dilators. I call them my white plastic boyfriends. And do not forget the lube!”

Other options to consider if lubricants and other strategies are not sufficient include:

Low-dose local (vaginal) estrogens
, in very small amounts, are highly effective at relieving vaginal dryness. They can also restore thickness and flexibility to the tissues in the vulva and vagina. Preparations include: Estring (a Silastic ring that you insert like a diaphragm and leave in for up to three months), Vagifem tablets, and Estrace and Premarin creams. There is also Estriol, a bioidentical vaginal cream made by compounding pharmacies. These products have a local effect, and far less estrogen gets into the bloodstream than it does with oral or transdermal (patch) estrogen medications.

The ring delivers a minuscule amount of estrogen to the bloodstream and the tablets send a little more, though the dose delivered in the tablet has recently been reduced. Regrettably, there are no long-term studies that demonstrate if even these small amounts of estrogens have risks, but they definitely improve the quality of life for many women.

If you use a vaginal estrogen cream, keep in mind that it can send a larger and somewhat unpredictable amount of estrogen into the bloodstream, depending how much is used and how often it is used. Most women initially require nightly treatment, but many women find that a smaller dose than prescribed works fine, especially if they are sexually active. Try using just enough to cover a fingertip and apply it to the opening of the vagina; the applicators tend to deliver a systemic dose of estrogen and deposit it higher than necessary. Estrogen cream should not be used as a lubricant for intercourse because it can be absorbed through a partner's skin.

If you're among the small number of women who have persistently sore breasts while using vaginal estrogen, try decreasing the dose to see if that will eliminate the soreness. If soreness persists, consult your health care provider.

Hormone therapy
that includes systemic estrogen is also effective at relieving vaginal dryness. However, since low-dose local estrogens work well, it is typically not necessary to resort to systemic HT.

If vaginal dryness is an issue, getting help can make a big difference. A sixty-three-year-old woman recalls a time when she had not had sex for a number of months and sex was very uncomfortable:

I was so dry and tender that it felt like my partner had gravel on his fingers. I was really alarmed but started to use vaginal estrogen. I love sex, and it was such a relief to feel like I had my clit and my vagina back as a place of pleasure!

Some women at midlife report having to pee more often and needing to get up a few times during the night. Some also experience urinary incontinence (UI), of which there are two types. Urge incontinence is a sudden strong urge to urinate followed by an involuntary flow; it begins for some women in perimenopause and improves after menopause. Stress incontinence is the involuntary leaking of urine when coughing, sneezing, laughing, or exerting oneself during strenuous activity.

Urinary incontinence is more common at older ages. Lower estrogen levels seem to be involved in some types of UI but not all. In the Women's Health
Initiative (WHI) trials
, higher estrogen levels caused incontinence and worsened already existing incontinence. It doesn't seem to be just synthetic estrogens that are the culprit—even studies of estrogen patches or gels show mixed results. Some medications and caffeinated beverages can make you pee more often, and even as little as 500 mg of vitamin C may cause urinary urgency and sometimes incontinence. Mobility problems can be a factor, too, when you can't get to a toilet fast or on your own at all.

Urinary incontinence and having to pee frequently can sometimes indicate that you have a urinary tract infection. The low estrogen and progesterone levels in late perimenopause and postmenopause can result in thinning of the urinary tract tissues and a weakening of the bladder and urethra (the tube from the bladder to the outside), increasing susceptibility to urinary infections. So if you are having urinary problems, make sure to check for an underlying infection (see
“Urinary Tract Infections”
).

Incontinence can be successfully managed, treated, and sometimes even cured. Besides wearing panty liners, you can try these self-help and medical approaches:

Kegel exercises
. At all ages, strengthening the muscles of the pelvic floor will help control urine leaks. If you have never done Kegel (perineal) exercises, this is a good time to start and
keep doing them
.

Bladder training
. Teaching yourself to go longer and longer without urinating can also be very helpful. Sit on the toilet every two hours, whether you have to go or not. Then, every two days, extend the interval by thirty minutes until you're doing it every four hours. Try to maintain the schedule whether or not you have an accident. If you have an urge to urinate, stay still and use the muscle-strengthening exercises until the urge passes, then move slowly to the bathroom. Sometimes it helps to relax the body rather than tense up all over in an attempt to hold the urine back. Avoid drinking a lot of fluid before you go out or while you're away from home, and catch up with liquids when you return home.

Medications
. Some medications help decrease bladder contractions (hyperactive bladder) that produce leaking. Some are relatively new, and they may not help your particular urinary problem, so it's a good idea to get more information before deciding to take them. Certain medications (Detrol and Ditropan) may have a negative impact on memory and the central nervous system.

Vaginal estrogen in the form of tablets, cream, or rings
. Vaginal estrogen can sometimes help with urgency, frequency, and urge incontinence and in the prevention of urogenital atrophy and recurrent urinary tract infections. But studies don't agree on whether taking whole-body (systemic) estrogen/progestin therapy reduces incontinence in postmenopausal women or makes it worse.
12
The most common type of estrogen pills used in the past, conjugated equine estrogens (Premarin), appear to make it worse—with or without a progestin.

Some leaking of urine is caused by anatomical problems (see
“Pelvic Relaxation and Uterine Prolapse”
). Weakening of the tissues with age is sometimes related to damage from childbirth. To treat this, a pessary (which resembles a diaphragm) can be inserted into the vagina to help keep the bladder and urethra in their correct positions and prevent leakage.

One of several types of surgery might correct anatomical issues causing urinary incontinence, but if you are thinking about this, be sure to have a thorough discussion of the risks and benefits with an experienced gynecologic surgeon or a specialist in female urology. As with any major surgery, understand what is proposed and get another opinion before agreeing to any procedures. Ask about alternatives, the success rate, complications, and whether you might need to repeat the procedure if it doesn't work. Ask, too, how many of this kind of procedure the surgeon has done.

Finding help can be challenging, because female reproduction and urology are separate medical specialties. Most urologists know little more than the basics about female reproductive organs, while not all clinicians in either specialty know much about treating middle-aged and older women with urinary problems. Urogynecology is a relatively new subspeciality of ob-gyn in which gynecologists have additional special training in urogynecologic surgery.

Sexual problems are by no means universal in perimenopause and postmenopause. For example, one woman reported happily that “my libido was stronger than ever, and I was fortunate to have a husband who enjoyed pleasing me.” But many women in perimenopause report decreased sexual interest, lack of arousability, lack of sufficient vaginal lubrication (see above for ways of handling this), and sometimes even aversion to sex. These can be affected by perimenopause-related problems such as heavy, unpredictable menstrual periods or mood swings and may improve with the arrival of postmenopause
if you continue to be sexually active with yourself or a partner.

Sexual desire and function can be affected by other health problems, such as high blood pressure or diabetes, or life changes, such as the death of a partner or having a partner who is no longer interested or able to engage in sex.

If you have problems with changing sexual desire or experiences that are troubling to you, try to address specific problems before linking them to perimenopause or postmenopause. If you or your partner takes a medication that seems to be reducing sexual desire, discuss your concerns with your health care provider. Often substituting a different drug will help. If sex is uncomfortable, discuss it with your health care provider. The section on
“Painful Intercourse/Penetration”
, may also be helpful.

Be aware of the range of nonmedical factors that might be affecting your sexual satisfaction, including relationship issues, inadequate sex education, or difficulty talking about what you like or need for full satisfaction. The brain is an important sex organ, and if you are feeling stressed, tired, or annoyed (or angry) at a partner, you might not feel at all sexual. If there are issues in your relationship, seek a way to spend time with your partner to see whether you can sort things out. Finally, if you have also lost interest in other activities, consider whether or not you might be depressed, as not taking pleasure in activities you have enjoyed in the past is a common sign of depression. For more on desire, including a discussion of testosterone treatment as well as the effects of hormones and medications, see “Sexual Challenges,”
Chapter 8
. For more on sexuality in postmenopause, see
“Sexuality,”
in
Chapter 21
, “Our Later Years.”

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