CLINICAL GYNAECOLOGY
Management of vaginal dryness Elizabeth Key RGN, RM. is Research Sister, Menopause Clinic, King’s College Hospital, London. Sara Smith RGN is Research Sister, Menopause Clinic, Queen Charlotte's & Chelsea Hospital, London.
Fig. 1. Anatomy of the vulva and vagina, illustrating the changes in the relative dimensions before, during and after the reproductive
Vaginal dryness is a problem which brings physical and emotional distress to many women, but as yet little relevant research has been evident. Elizabeth Key and Sara Smith discuss the causes and treatments of the condition and report on current work aimed at relieving the irritating symptoms.
Vaginal dryness is a very common problem and one which many women suffer in silence. Although it is traditionally considered to be a problem which primarily afflicts menopausal women, it can also occur at any time during the reproductive years. It is not a subject which has attracted a great deal of research attention because, unlike cancer and heart disease, it lacks dramatic and life-threatening implications. Vaginal dryness is an ailment which is invisible to others and hence does not carry any social stigma, unlike, for example, uri nary incontinence, which can be profoundly embarrassing. It might also be argued that the medical profession is not particularly con cerned with this issue, which is probably perceived as 'trivial'. However, a great deal of discomfort and unhappiness can result from it. The most common way in which vaginal dryness manifests itself is during sexual inter course, causing considerable pain and leading eventually to apareunia. Vaginal dryness can also give rise to soreness, irritation and chafing, for example when wearing tight 1-10
Birth
years
Puberty
trousers, jeans or even during walking or sitting. Many women will also complain of dryness towards the end of a menstrual period which can make insertion of tampons ex tremely uncomfortable. The purpose of this article is firstly to examine the physiological basis of the prod uction of vaginal moisture and then to look at certain conditions and situations in which this might be profoundly disturbed. Finally, we will look at some of the treatments currently available and discuss their merits and disadvantages.
Physiology of moisture Production of vaginal moisture can be con sidered as two distinct but related physiologi cal processes. First, it is important to stress that the normal, healthy vagina in the pre menopausal woman is naturally moist at all times. This normal moisture has an acid pH (3.4-5.5), which protects against infection. Second, we will consider the increased mois ture and lubrication within the vagina and the introitus which occurs during sexual arousal. Vaginal moisture, as indeed moisture in any of the body's orifices, is derived from blood and is thus dependent upon an intact blood supply. In the pre-menopausal woman in the nonaroused state, vaginal moisture primarily Adult Parous
Postmenopause
i MU!
stage.
Labia Majora Labia Minora Hymen Vagina Bartholin’s Gland
24 Nursing Standard
April 24/Volurne 5/Number 31
1991
o
0
St
m
CLINICAL GYNAECOLOGY 377
'I
i-
» -r
i&S' .
«
Fig. 2. Microscopic appearances of cross-section taken through the vaginal epithelium in pre-menopausal (top) and post-menopausal (bottom) women, showing the mardkedly reduced superficial cell thickness of the vaginal epithelium.
comes from two sources: as a transudate through the vaginal epithelium from the surrounding network of blood vessels, and from the mucus produced within the endocervical glands - this is more profuse in mid cycle and lessens during the luteal phase under progestogenic influence. The vagina itself does not contain mucus-producing glands. During sexual arousal, there is a marked increase in the blood flow' within the vessels surrounding the vagina w'ith a subsequent increase in the transudation of fluid through the vaginal epithelium, which serves to lubri cate the inner parts of the vagina. The most noticeable increase in vaginal moisture comes from the secretions from the Bartholin's glands which are situated at the introitus. These secrete profusely and facil itate penetration. It should be clear from the above that anything which impairs the blood flow' to the vulva and vaginal areas, such as drugs or hormones, can reduce production of moisture. Anxiety, nervousness and failure to relax during intercourse can also lead to a reflex inhibition of production of adequate moisture to allow' intercourse to occur comfortably. There is now considerable evidence that oestrogens profoundly affect the blood flow to pelvic organs such as the uterus. One study has showm that administration of postme nopausal oestrogens can lead to reduced impe dance to flow within the uterine artery by as much as 50 per cent (1). We will now proceed to discuss actual situations in which vaginal dryness can arise and attempt to explain the pathophysiology associated with the states. Post-menopausal and peri-menopausal women are the most common group that complain of vaginal dryness. The central feature of the menopause is ovarian failure and lack of oestrogen production. Ovarian failure gradually begins in the middle 40s and the end stage is reached when periods actually cease. Oestrogen deprivation progressively leads to a marked drop in capillary vaginal and vulval blood supply, w'hich manifests as decreased lubrication. In a study at the King's College Menopause Clinic, it was found that within one year of the cessation of periods, ten per cent of women complained that vaginal dryness was a significant problem, and within five years of the last menstrual period 40 per cent of women said it was a significant problem (2). In addition, the vagina tends to become narrower and shorter as the woman becomes older (Fig. 1). The lack of moisture is compounded in post-menopausal women by the fact that the vaginal epithelium becomes thinner and less elastic (Fig. 2), and there may
26 Nursing Standard April 24/Volume 5/Numbcr 31 1991
be a loss of collagen from the underlying tissues. It has been suggested that regular intercourse helps to maintain the vagina in a sexually functional state.
Treatment of dry ness Lubricating agents The most common reme dies used by menopausal women are lubri cating creams or jellies. These are quite literally lubricants which reduce friction. The major drawback of the currently available lubricating jellies is that they affect the spontaneity of sexual enjoyment and have to be used just prior to intercourse. They also quite often have to be ‘topped up’ during intercourse and, being aqueous compounds, they naturally tend to dry out fairly quickly. Oestrogen creams Topical oestrogen creams are also used by a number of women and have to be obtained on prescription. They may, like systemic oestrogens, increase capillary blood flow to the vagina and vulval area and hence restore moisture. However, there are certain drawbacks. It has been shown from some studies that when oestrogen vaginal creams are applied, a significant degree of systemic absorption takes place because the vaginal epithelium is an extremely good medium for absorbing hormones and other drugs (3,4). If oestrogen-containing creams are used on a regular basis in liberal quantities, oestrogen is absorbed in significant amounts into the peripheral circulation and can cause endo metrial stimulation (3); if this is not ‘opposed' with an added progestogen it can lead to endometrial hyperplasia and carcinoma (5). There is also one report in the literature that oestrogen vaginal cream had been absorbed through the skin of the penis and had given rise to gynaecomastia in the male partner (4). Another disadvantage of oestrogen vaginal cream is its appearance. Most of the available preparations have a thick white colour and some women find them aesthetically unac ceptable. One particular vaginal preparation has an unpleasant odour. Hormone replacement therapy Conventional hormone replacement therapy (HRT) is gen erally very effective in relieving vaginal dry ness and dyspareunia. HRT also has a number of beneficial effects in preventing osteoporosis and ischaemic heart disease but one of its major disadvantages is the resumption of monthly withdrawal bleeds. Many women who are relatively asymptomatic from the point of view of flushes and sweats will simply not accept this. ’I here is also a group of women in whom the standard doses of oral and transdermal
CLINICAL GYNAECOLOGY
References 1. Bourne T et al. Oestrogens, arterial status and postmenopausal women. The Lamer. 1990. 335, 1470-1471. 2. Whitehead M 1. Unpublished data. London, King’s College Hospital. 3. Whitehead M I et al. Systemic absorption of estrogen from Premarin vaginal cream. In Cooke I (ed) The Role of Estrogen!Progestogen in the Management of the Menopause. Lancaster, MTP Press. 1978. 4. Di Raimundo C V et al. Gynecomastia from exposure to vaginal oestrogen cream. N EnglJ Med. 1980. 302, 1089-1090. 5. Whitehead M I et al. Effects of estrogens and progestins on the bio-chemistry and morphology of the postmenopausal endometrium. N Engl J Med. 1981. 305, 1599-1605. 6. Reginald P W et al. Medroxyprogesterone acetate in the treatment of pelvic pain due to venous congestion. DrJ Obstet Gynaecol. 1989. 96, 1148-1152. 7. Cusr M P et al. The psychosexual and endocrine consequences of ovarian failure following bone marrow transplantation with total body irradiation as treatment for leukaemia. Br Med J. 1989. 299, 1494-1497. 8. Sarrel P M, Whitehead M I. Sex and the menopause. Defining the issues. Maturitas. 1985. 7, 217-224.
hormone replacement therapy will not en tirely cure the problem of vaginal dryness. An unknown percentage of women on such hor mone replacement therapy continue to suffer a degree of dryness, perhaps because the plasma oestrogen levels which are achieved are lower than those found during the premenopausal era. We are currently undertaking a research project which is investigating the role of vaginal moisturiser in alleviating this prob lem. This will be discussed further. Breastfeeding Women who breastfeed for long periods have a marked suppression of ovarian activity with oestrogen levels almost as low as those of postmenopausal women. Breastfeeding acts via the hypothalmopituitary ovarian axis and leads to a suppres sion ot ovulation. This explains why breastfeeding is often assumed to be a form of contraception, which can be notoriously unre liable! Lactating women, not surprisingly, can experience vaginal dryness as a significant problem, frequently compounded by the fact that many of these women may have had episiotomies or other vaginal lacerations, which can take some time to heal. When intercourse is attempted, some discomfort can be experienced, which can then trigger off anxiety, failure to relax and exacerbation of the lubrication problem. Hormones Many hormonal drugs, including the combined oral contraceptive pill, contain significant quantities of progestogens. There is evidence to suggest that progestogens reduce blood flow within the pelvis (6). Thus, some women on the pill may experience dryness. Potent progestogens, such as norethisterone, are commonly prescribed for menorrhagia and women taking these drugs may also experience dryness. Other drugs, such as Danazol. have a marked antioestrogenic effect. The drug Tamoxifen, which is used exten sively in the treatment ot breast carcinoma, also has anti-oestrogenic properties. All of these can be associated with vaginal dryness and the attendant problems which have al ready been referred to above. A particularly sad and distressing group of women are those who have undergone a premature menopause either spontaneously or due to treatment with chemotherapy or radiotherapy for malignant disease such as leukaemia (7). One recent study reported vaginal dryness as the most common com plaint among this group, a complaint which profoundly affected their sex life and general sense of femininity and well-being (8). Oestrogen-dependent cancers, such as breast cancer, pose particular difficulties be
cause the therapeutic objective of treatment by irradiating or removing the ovaries is to reduce oestrogen levels. Giving oestrogens to control resultant dryness may, therefore, be entirely inappropriate. However, with premature menopause which has arisen spon taneously or secondary to chemotherapy or radiotherapy for a non-hormone dependent condition (such as leukaemia), oestrogens can be prescribed. Anxiety and stress It has been said that normal, healthy vaginal lubrication in women during sexual intercourse is the counterpart of penile erection in the male. It is therefore not surprising that dryness causes similar distress and unhappiness as erectile failure. There may often be a history of psychosexual problems, sexual abuse in one form or another, or unhappy memories from past sexual encoun ters. Considerable strain can arise within a relationship due to subsequent feelings of rejection on the part of the male partner. There is also a small group of women in whom there appears to be a ‘constitutional' factor, ie there is no underlying physical, endocrine, emotional or psychosexual prob lem; this group simply does not seem to lubricate properly during intercourse, for unknown reasons.
Current studies Current studies in progress at King’s College and Queen Charlotte's and Chelsea clinics involve looking at the compound polycarbophil, a long-chain polyacid which is not absorbed systemically and is known as a 'bioadhesive’. This simply means that it has the ability to attach itself to epithelial surfaces and remain in place for up to 72 hours after a single application. It also has the ability to retain up to 60 times its own weight in water. When polycarbophil is applied to the vagina it adheres to the epithelium and slowly releases water which rehydrates the epithelial cells. This process continues for up to 72 hours, after which time a further application is administered. It is claimed that by use of the compound two or three times a week the vagina is kept in a permanently moist state and any moisture produced during sexual intercourse is fixed by the polycarbophil system and is not lost. Another potentially important advance of polycarbophil is its ability to restore and maintain a physiological vaginal pH which may have a role in protecting the vagina against recurrent infection from organisms such as Candida and Gardnerella. April 24/Volume 5/N‘umber 31 1991 Nursing Standard 27
Management of vaginal dryness Elizabeth Key RGN, RM. is Research Sister, Menopause Clinic, King’s College Hospital, London. Sara Smith RGN is Research Sister, Menopause Clinic, Queen Charlotte's & Chelsea Hospital, London.
Fig. 1. Anatomy of the vulva and vagina, illustrating the changes in the relative dimensions before, during and after the reproductive
Vaginal dryness is a problem which brings physical and emotional distress to many women, but as yet little relevant research has been evident. Elizabeth Key and Sara Smith discuss the causes and treatments of the condition and report on current work aimed at relieving the irritating symptoms.
Vaginal dryness is a very common problem and one which many women suffer in silence. Although it is traditionally considered to be a problem which primarily afflicts menopausal women, it can also occur at any time during the reproductive years. It is not a subject which has attracted a great deal of research attention because, unlike cancer and heart disease, it lacks dramatic and life-threatening implications. Vaginal dryness is an ailment which is invisible to others and hence does not carry any social stigma, unlike, for example, uri nary incontinence, which can be profoundly embarrassing. It might also be argued that the medical profession is not particularly con cerned with this issue, which is probably perceived as 'trivial'. However, a great deal of discomfort and unhappiness can result from it. The most common way in which vaginal dryness manifests itself is during sexual inter course, causing considerable pain and leading eventually to apareunia. Vaginal dryness can also give rise to soreness, irritation and chafing, for example when wearing tight 1-10
Birth
years
Puberty
trousers, jeans or even during walking or sitting. Many women will also complain of dryness towards the end of a menstrual period which can make insertion of tampons ex tremely uncomfortable. The purpose of this article is firstly to examine the physiological basis of the prod uction of vaginal moisture and then to look at certain conditions and situations in which this might be profoundly disturbed. Finally, we will look at some of the treatments currently available and discuss their merits and disadvantages.
Physiology of moisture Production of vaginal moisture can be con sidered as two distinct but related physiologi cal processes. First, it is important to stress that the normal, healthy vagina in the pre menopausal woman is naturally moist at all times. This normal moisture has an acid pH (3.4-5.5), which protects against infection. Second, we will consider the increased mois ture and lubrication within the vagina and the introitus which occurs during sexual arousal. Vaginal moisture, as indeed moisture in any of the body's orifices, is derived from blood and is thus dependent upon an intact blood supply. In the pre-menopausal woman in the nonaroused state, vaginal moisture primarily Adult Parous
Postmenopause
i MU!
stage.
Labia Majora Labia Minora Hymen Vagina Bartholin’s Gland
24 Nursing Standard
April 24/Volurne 5/Number 31
1991
o
0
St
m
CLINICAL GYNAECOLOGY 377
'I
i-
» -r
i&S' .
«
Fig. 2. Microscopic appearances of cross-section taken through the vaginal epithelium in pre-menopausal (top) and post-menopausal (bottom) women, showing the mardkedly reduced superficial cell thickness of the vaginal epithelium.
comes from two sources: as a transudate through the vaginal epithelium from the surrounding network of blood vessels, and from the mucus produced within the endocervical glands - this is more profuse in mid cycle and lessens during the luteal phase under progestogenic influence. The vagina itself does not contain mucus-producing glands. During sexual arousal, there is a marked increase in the blood flow' within the vessels surrounding the vagina w'ith a subsequent increase in the transudation of fluid through the vaginal epithelium, which serves to lubri cate the inner parts of the vagina. The most noticeable increase in vaginal moisture comes from the secretions from the Bartholin's glands which are situated at the introitus. These secrete profusely and facil itate penetration. It should be clear from the above that anything which impairs the blood flow' to the vulva and vaginal areas, such as drugs or hormones, can reduce production of moisture. Anxiety, nervousness and failure to relax during intercourse can also lead to a reflex inhibition of production of adequate moisture to allow' intercourse to occur comfortably. There is now considerable evidence that oestrogens profoundly affect the blood flow to pelvic organs such as the uterus. One study has showm that administration of postme nopausal oestrogens can lead to reduced impe dance to flow within the uterine artery by as much as 50 per cent (1). We will now proceed to discuss actual situations in which vaginal dryness can arise and attempt to explain the pathophysiology associated with the states. Post-menopausal and peri-menopausal women are the most common group that complain of vaginal dryness. The central feature of the menopause is ovarian failure and lack of oestrogen production. Ovarian failure gradually begins in the middle 40s and the end stage is reached when periods actually cease. Oestrogen deprivation progressively leads to a marked drop in capillary vaginal and vulval blood supply, w'hich manifests as decreased lubrication. In a study at the King's College Menopause Clinic, it was found that within one year of the cessation of periods, ten per cent of women complained that vaginal dryness was a significant problem, and within five years of the last menstrual period 40 per cent of women said it was a significant problem (2). In addition, the vagina tends to become narrower and shorter as the woman becomes older (Fig. 1). The lack of moisture is compounded in post-menopausal women by the fact that the vaginal epithelium becomes thinner and less elastic (Fig. 2), and there may
26 Nursing Standard April 24/Volume 5/Numbcr 31 1991
be a loss of collagen from the underlying tissues. It has been suggested that regular intercourse helps to maintain the vagina in a sexually functional state.
Treatment of dry ness Lubricating agents The most common reme dies used by menopausal women are lubri cating creams or jellies. These are quite literally lubricants which reduce friction. The major drawback of the currently available lubricating jellies is that they affect the spontaneity of sexual enjoyment and have to be used just prior to intercourse. They also quite often have to be ‘topped up’ during intercourse and, being aqueous compounds, they naturally tend to dry out fairly quickly. Oestrogen creams Topical oestrogen creams are also used by a number of women and have to be obtained on prescription. They may, like systemic oestrogens, increase capillary blood flow to the vagina and vulval area and hence restore moisture. However, there are certain drawbacks. It has been shown from some studies that when oestrogen vaginal creams are applied, a significant degree of systemic absorption takes place because the vaginal epithelium is an extremely good medium for absorbing hormones and other drugs (3,4). If oestrogen-containing creams are used on a regular basis in liberal quantities, oestrogen is absorbed in significant amounts into the peripheral circulation and can cause endo metrial stimulation (3); if this is not ‘opposed' with an added progestogen it can lead to endometrial hyperplasia and carcinoma (5). There is also one report in the literature that oestrogen vaginal cream had been absorbed through the skin of the penis and had given rise to gynaecomastia in the male partner (4). Another disadvantage of oestrogen vaginal cream is its appearance. Most of the available preparations have a thick white colour and some women find them aesthetically unac ceptable. One particular vaginal preparation has an unpleasant odour. Hormone replacement therapy Conventional hormone replacement therapy (HRT) is gen erally very effective in relieving vaginal dry ness and dyspareunia. HRT also has a number of beneficial effects in preventing osteoporosis and ischaemic heart disease but one of its major disadvantages is the resumption of monthly withdrawal bleeds. Many women who are relatively asymptomatic from the point of view of flushes and sweats will simply not accept this. ’I here is also a group of women in whom the standard doses of oral and transdermal
CLINICAL GYNAECOLOGY
References 1. Bourne T et al. Oestrogens, arterial status and postmenopausal women. The Lamer. 1990. 335, 1470-1471. 2. Whitehead M 1. Unpublished data. London, King’s College Hospital. 3. Whitehead M I et al. Systemic absorption of estrogen from Premarin vaginal cream. In Cooke I (ed) The Role of Estrogen!Progestogen in the Management of the Menopause. Lancaster, MTP Press. 1978. 4. Di Raimundo C V et al. Gynecomastia from exposure to vaginal oestrogen cream. N EnglJ Med. 1980. 302, 1089-1090. 5. Whitehead M I et al. Effects of estrogens and progestins on the bio-chemistry and morphology of the postmenopausal endometrium. N Engl J Med. 1981. 305, 1599-1605. 6. Reginald P W et al. Medroxyprogesterone acetate in the treatment of pelvic pain due to venous congestion. DrJ Obstet Gynaecol. 1989. 96, 1148-1152. 7. Cusr M P et al. The psychosexual and endocrine consequences of ovarian failure following bone marrow transplantation with total body irradiation as treatment for leukaemia. Br Med J. 1989. 299, 1494-1497. 8. Sarrel P M, Whitehead M I. Sex and the menopause. Defining the issues. Maturitas. 1985. 7, 217-224.
hormone replacement therapy will not en tirely cure the problem of vaginal dryness. An unknown percentage of women on such hor mone replacement therapy continue to suffer a degree of dryness, perhaps because the plasma oestrogen levels which are achieved are lower than those found during the premenopausal era. We are currently undertaking a research project which is investigating the role of vaginal moisturiser in alleviating this prob lem. This will be discussed further. Breastfeeding Women who breastfeed for long periods have a marked suppression of ovarian activity with oestrogen levels almost as low as those of postmenopausal women. Breastfeeding acts via the hypothalmopituitary ovarian axis and leads to a suppres sion ot ovulation. This explains why breastfeeding is often assumed to be a form of contraception, which can be notoriously unre liable! Lactating women, not surprisingly, can experience vaginal dryness as a significant problem, frequently compounded by the fact that many of these women may have had episiotomies or other vaginal lacerations, which can take some time to heal. When intercourse is attempted, some discomfort can be experienced, which can then trigger off anxiety, failure to relax and exacerbation of the lubrication problem. Hormones Many hormonal drugs, including the combined oral contraceptive pill, contain significant quantities of progestogens. There is evidence to suggest that progestogens reduce blood flow within the pelvis (6). Thus, some women on the pill may experience dryness. Potent progestogens, such as norethisterone, are commonly prescribed for menorrhagia and women taking these drugs may also experience dryness. Other drugs, such as Danazol. have a marked antioestrogenic effect. The drug Tamoxifen, which is used exten sively in the treatment ot breast carcinoma, also has anti-oestrogenic properties. All of these can be associated with vaginal dryness and the attendant problems which have al ready been referred to above. A particularly sad and distressing group of women are those who have undergone a premature menopause either spontaneously or due to treatment with chemotherapy or radiotherapy for malignant disease such as leukaemia (7). One recent study reported vaginal dryness as the most common com plaint among this group, a complaint which profoundly affected their sex life and general sense of femininity and well-being (8). Oestrogen-dependent cancers, such as breast cancer, pose particular difficulties be
cause the therapeutic objective of treatment by irradiating or removing the ovaries is to reduce oestrogen levels. Giving oestrogens to control resultant dryness may, therefore, be entirely inappropriate. However, with premature menopause which has arisen spon taneously or secondary to chemotherapy or radiotherapy for a non-hormone dependent condition (such as leukaemia), oestrogens can be prescribed. Anxiety and stress It has been said that normal, healthy vaginal lubrication in women during sexual intercourse is the counterpart of penile erection in the male. It is therefore not surprising that dryness causes similar distress and unhappiness as erectile failure. There may often be a history of psychosexual problems, sexual abuse in one form or another, or unhappy memories from past sexual encoun ters. Considerable strain can arise within a relationship due to subsequent feelings of rejection on the part of the male partner. There is also a small group of women in whom there appears to be a ‘constitutional' factor, ie there is no underlying physical, endocrine, emotional or psychosexual prob lem; this group simply does not seem to lubricate properly during intercourse, for unknown reasons.
Current studies Current studies in progress at King’s College and Queen Charlotte's and Chelsea clinics involve looking at the compound polycarbophil, a long-chain polyacid which is not absorbed systemically and is known as a 'bioadhesive’. This simply means that it has the ability to attach itself to epithelial surfaces and remain in place for up to 72 hours after a single application. It also has the ability to retain up to 60 times its own weight in water. When polycarbophil is applied to the vagina it adheres to the epithelium and slowly releases water which rehydrates the epithelial cells. This process continues for up to 72 hours, after which time a further application is administered. It is claimed that by use of the compound two or three times a week the vagina is kept in a permanently moist state and any moisture produced during sexual intercourse is fixed by the polycarbophil system and is not lost. Another potentially important advance of polycarbophil is its ability to restore and maintain a physiological vaginal pH which may have a role in protecting the vagina against recurrent infection from organisms such as Candida and Gardnerella. April 24/Volume 5/N‘umber 31 1991 Nursing Standard 27
