5 things every woman should know about Painful Sex

Here's a painful fact: Although roughly half of midlife women complain of vaginal dryness and painful sex, only 7% are treated.

And here is the painful truth: most women are embarrassed to tell their providers about this problem and most providers don't ask their patients about it.

Here's the good news: There are five treatments you should know about so you can discuss them with your healthcare provider.

1. Get a diagnosis

 The most common cause of this problem is low estrogen, but a small percentage of women have a skin disorder called vulvar dystrophy. An even smaller percentage of women have cancer of the vulva. These are uncommon but they cause a lot of discomfort and many times don't get diagnosed for a long time.

Another common cause of dryness and painful sex is vaginal infection. Other women have had pelvic radiation or are being treated with estrogen-blocking medications for cancer treatment.

So have an exam by a good healthcare provider who knows their stuff so you know what you've got. If your doctor tells you, "There's nothing that can be done," get another opinion.

2. Local vaginal estrogen

The vaginal tissues are very elastic and can stretch to allow a baby safe passage through it and then return to its smaller size. It's like the ribbing of a sock or sleeve. Your foot or hand passes through and then the elasticity allows the sock or sleeve to go back to normal. The vagina works similarly to that.

Starting at the time of menopause, lower estrogen levels cause the tissues of the vagina to begin losing their elasticity. The tissues get shorter, narrower and thinner.

The lower blood flow leads to less moisture and flatter, paler tissues, and that leads to dryness and eventually to painful sex.

Often it takes two to three years after menopause for these symptoms to show up and because they become a problem so long after menopause, they don't seem related — but they are.

The medical term for this has been vaginal atrophy. It was such an awful sounding name that the North American Menopause Society recently renamed it Genitourinary Syndrome of Menopause. Still doesn't roll off your tongue, but that's what it's called.

Local estrogen placed on the inner and outer genital area work really well in providing relief and reversing this problem. There's a vaginal ring (Estring) replaced every three months, a vaginal estrogen tablet (Vagifem) that is used daily for two weeks then twice weekly after that, and vaginal creams such as Estrace, Premarin and others.

These all allow very small amounts of estrogen to enter the blood stream; so small they are considered inconsequential.

But many women fear estrogen even when it is given locally. There is a good reason why — the "black box" warning on the prescription is required to say that estrogen can cause breast cancer, blood clots and stroke — even though that has largely been disproven even for oral and topical estrogen and has never been the case for local estrogen.

In March 2016 the American College of Obstetricians and Gynecologists published a position statement and stated that if other methods don't work, estrogen can be used locally for dryness and painful sex in women who are either in remission for or who are being actively treated for estrogen receptor positive breast cancer, even though a little bit gets into the blood stream.

As Bob Dylan, who recently won the Nobel Prize in literature wrote, "The times, they are a changing." There is no evidence that local estrogen causes either worsening of outcomes or recurrence of estrogen receptor positive breast cancer. There is no reason to be afraid to use it.

As I point out in my best selling book, “The Estrogen Window,” there are specific windows of opportunity for estrogen to work most effectively and most safely on most organs of the body.

Not so for the vagina — the estrogen window for the vaginal tissues stays open and estrogen virtually always improves the symptoms and offers relief.

If you still prefer not using estrogen, here are three more options to be aware of.

3. Local lidocaine gel

Most people know about lidocaine as a local anesthetic. It's similar to the stuff that gets injected into your mouth before dental work, or other similar types of uses. One interesting study by Dr. Martha Goetsch used 4% lidocaine gel for painful sex.

It requires getting a prescription from your doctor. Just before having intercourse, place a tablespoon of 4% lidocaine into a small glass and drop in a cotton ball. Take the soaking wet cotton ball and put in into the lower vagina for about three minutes.

Throw out the cotton ball, get your favorite lubricant and that's it. Most women find it works great. It's not a treatment but it prevents the pain.

4. Osphena (Ospemifene)

Osphena is a medication that was approved in 2013 for painful sex. It's a type of medicine called a SERM, which stands for Selective Estrogen Receptor Modulator. You probably know of other SERMS such as Tamoxifen and Raloxifene.

This once-a-day pill causes vaginal moisture and relieves painful sex, and doesn't harm the breasts. Some women do have hot flashes, nausea, headaches and mild joint pain, but overall, women like the medication and think it works very well.

5. Mona Lisa Touch

Mona Lisa Touch is a laser that is used in the vagina. A probe about the size of your thumb goes into the vagina during a routine pelvic exam. Laser beams come out of the sides of the probe and laser microscopic holes into the vagina that are very superficial. There is no bleeding and no pain. The entire procedure takes about five minutes.

The procedure is usually done three times over six weeks and then is repeated in about one year.

How does it work? New blood vessels come into the little holes and allow the vagina to restore its more youthful and elastic self.

The procedure is not covered by insurance and each laser treatment is about $1,000. We don't have any long-term information because it is a new procedure but it appears to work well. The instrument is FDA approved. Although it is available in many cities, it is not yet available everywhere.

In the new year there will be a new hormonal treatment for vaginal dryness and painful sex that is not estrogen. It is DHEA and it seems to give excellent relief and does not allow estrogen to enter the blood stream.

There is no need to suffer from dryness and painful sex. Get a good exam and get treated. Or get another opinion from someone who is more comfortable treating this condition.

Dr. Mache Seibel ( DrMache.com ) one of America's leading experts on women's wellness and menopause, is author of "The Estrogen Window" and editor of The Hot Years — My Menopause Magazine.
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