Treating vaginal atrophy in menopausal women

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Although women of all ages can experience distressing sexual health related issues, women in menopause are more prone to them, particularly vaginal atrophy, which can lead to lack of vaginal moisture and painful intercourse, according to JoAnn Pinkerton, MD. Pinkerton is a professor of obstetrics and gynecology at University of Virginia Health System in Charlottesville, Va. and executive director of the North American Menopause Society (NAMS).

While some women are proactive about discussing these issues with their OB/GYNs, many are likely to see their primary care physician first. These physicians should also be able to discuss and treat this normal but uncomfortable part of menopause, Pinkerton says. 

Educate patients

The most important thing a physician can do is educate themselves so they can help menopausal women know that what is happening to them is normal, and there are treatment options, Pinkerton says.

She recommends NAMS’ sexual health website, and the International Society for the Study of Women’s Health as resources.

“Many women don’t understand that this is a medical issue associated with the loss of vaginal hormones,” says Pinkerton.

Pinkerton explains that in menopause, “Women lose the top layer of superficial cells in the vaginal wall, which keep the vaginal pH in normal range and full of healthy bacteria.” 

This leads to changes in the vagina such as overgrowth of pathogenic organisms, which can lead to frequent yeast infections that affect vaginal ph. As the lining of the vagina thins, blood vessels increase, and elasticity decreases, which can cause spasms in the levator muscles of the vagina, contributing to painful intercourse.

Treatment options

Physicians should bring awareness to this issue, Pinkerton says, because “vaginal atrophy can interfere with a woman’s sexual activity, relationships and even self-esteem.”

Pinkerton typically begins by recommending over-the-counter vaginal lubricants and moisturizers that can improve vaginal ph.

Additionally there are vaginal suppositories and non-estrogen vaginal rings that turn estrogen into testosterone in the vagina. There are also oral medications designed specifically to treat painful intercourse, and even some physical devices that may help increase vaginal lubrication and or arousal. Having an open dialogue with patients will better help physicians recommend the right treatment.

How to talk about it

Pinkerton says that embarrassment can prevent women from bringing up their symptoms with their physicians. While Pinkerton hopes women will be proactive, she encourages physicians to take an annual sexual history with all patients and then schedule a follow up appointment if necessary. 

Additionally, she says physicians should be sure to have one or more OB/GYNs to whom they can refer. 

When discussing this and other sensitive topics, Pinkerton recommends two communication models that can help physicians.  The first, she says, is called the “Plissit” model:

• Permission (P): Give the patient permission to discuss their concerns by asking questions.

• Limited information (li): The physician gives only as much information as is useful and necessary to the issue at hand.

• Specific suggestions (ss): Make specific suggestions the patient can take right away.

• Intensive therapy (it): If necessary, refer the patient out to another clinician with expertise in the area. 

The second model she describes is called “the Pearls method”:

• Partnership (P): Physician and patient work together to create a treatment plan.

• Empathy (E): The physician expresses understanding for what the patient is going through with phrases like “that sounds hard.”

• Apology/acknowledgment (A): The physician shows concern and or acknowledges the patient, such as saying, “I’m sorry for running late,” or “I wish things were different.”

• Respect (R): The physician demonstrates appreciation for the patient, such as, “You’ve obviously researched this subject well.”

• Legitimation (L): The physician reassures the patient their feelings are normal. “Anyone would feel upset by this.” 

• Support (S): The physician makes clear that they are going to support the patient even if they don’t have all the answers.

Overall, physicians should seek to normalize sexual health. 

“If the patient comes in to have an annual exam, and you’re thinking about blood pressure, pulse, stress, mammogram and pap smear, you should also be thinking about what’s happening in their genitourinary systems. An annual exam is an ideal way to get that information,” Pinkerton says.