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Joan Boone, 67, suffered severe vaginal dryness before she began using localized estrogen treatment.


Joan Boone, 67, says menopause killed her sex life. When she stopped getting her period at the early age of 39, her vagina became so dry that sexual intercourse became "really painful," she said.

Boone felt uncomfortable talking to her husband about why she was avoiding sex, she said. Instead, she blamed herself, thinking that her cycling workouts and frequent swimming in chlorinated pools were causing her symptoms.

Finally, when she reached her mid-50s, Boone mustered the courage to talk to a doctor about the vaginal irritation and lack of sexual intimacy she had endured for well over a decade.

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Her doctor prescribed an estrogen tablet to be inserted in her vagina twice a week. The treatment restored her vaginal moisture and elasticity, said Boone, who compared herself to the men in Viagra commercials: "I've been doing the happy dance."

Erectile dysfunction has largely lost its stigma because of that little blue pill. But the female equivalent – vaginal atrophy – is something many women are still too embarrassed to talk about, said Dr. Denise Black, co-chair of medical education at Sigma Canadian Menopause Society.

Up to half of all menopausal women may experience vaginal dryness or pain during intercourse. But despite being common, vaginal atrophy is so awkward for women to discuss that in August, the International Society for the Study of Women's Sexual Health and the North American Menopause Society endorsed a new term, GSM, which stands for "genitourinary syndrome of menopause."

The new term is more accurate, Black said, since menopausal symptoms also include recurring urinary-tract infections and the frequent urge to pee.

Menopause results in a thinning of the protective membranes in the vagina and urinary tract, reduced blood flow and a loss of elastin and collagen in the area, she explained. "They're all consequences of zero estrogen."

Nevertheless, not all menopausal women develop GSM. Non-smokers are less likely to suffer, since smoking reduces blood circulation, and vaginal deliveries appear to have a protective effect. The Mayo Clinic notes that regular sexual activity – with or without a partner – "increases blood flow and makes your tissues more elastic."

But the "use it or lose it" approach only goes so far, Black said. Sexual intercourse may slow the rate of vaginal narrowing, and Kegel exercises may help maintain muscle tone in the area, but neither restores elastin and collagen, she said.

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Women with mild symptoms may find that a thin, water-based lubricant reduces their discomfort during sex, she added. But for women with severe dryness, Black recommends estrogen creams, tablets inserted in the vagina or hormone-releasing vaginal rings that are left in for three months.

Still, specialists including Black emphasize that women's sexuality in menopause is not just a matter of vaginal dryness. Menopausal women may need gentler sex, and are less likely to suffer from dryness with a skilled and trusted partner who encourages a woman to take her time to get aroused, said Dr. Jerilynn Prior, an endocrinologist at the University of British Columbia's Centre for Menstrual Cycle and Ovulation Research. "That's the part about vaginal dryness that people forget," she said.

Although treatments for GSM contain only minuscule amounts of estrogen, some still contain too much estrogen for menopausal women, Prior added.

A review of 19 clinical trials by the esteemed Cochrane Library, which functions as an independent drug review board, found that estrogen creams, vaginal tablets and estrogen-releasing vaginal rings all improved symptoms of vaginal atrophy. In rare cases, however, the creams were associated with overstimulation of the uterine lining – a precursor to endometrial cancer, Prior said.

Estriol, the type of estrogen produced in pregnancy, "is the safest," she said. Prior recommends that women ask for a prescription for estriol cream, which must be compounded by a pharmacy since it is unavailable as a ready-made product. The cream should be used sparingly in a dose of 0.5 milligrams, no more than twice a week, she said, adding that sore breasts or vaginal bleeding are signs that menopausal women are getting too much estrogen.

Breast-cancer patients being treated with an aromatase inhibitor should not take estrogen treatments for vaginal dryness.

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But even when safely used, are these products – and the new diagnosis of GSM – just another way of pathologizing natural aging?

Black pointed out that "natural aging" is a blurry concept now that the average life expectancy in Canada has increased from 45 years in 1900 to the age of 80 today. As a culture, she said, "We are having to look at aging with not a lot of experience around it."

Boone said she's seen a lot of marriages fail among older couples, a phenomenon she attributes to a sexual disconnect. In her own marriage of 45 years, Boone said the feelings of intimacy returned after she received treatment for vaginal atrophy.

But it's hard to say whether her results are typical. In most cases, a woman's interest in sex is more closely associated with her feelings of energy and self-worth than her hormone levels, according to a recent study by Allison Macbeth, a researcher at UBC.

These feelings, Prior said, "are as much a part of women's sexuality as the genital blood flow, tissues and all the rest."

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