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Originally published Tuesday, August 7, 2012 at 6:00 AM

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Persistence is key to treating vaginal pain

Personal Health: Only about one-quarter of women with vaginal pain ever report the problem to a medical professional. And those who do speak up are often told — incorrectly — that nothing can be done.

The New York Times

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Millions of women experience vaginal discomfort, and sometimes crippling pain, for a variety of reasons, most often a loss of estrogen. The resulting vaginal dryness and atrophy can make sexual intercourse, a pelvic exam, urinating or even sitting, walking or cycling a painful nightmare.

In addition to women near or past menopause, those affected include women who have recently given birth or are breast-feeding, women treated with estrogen-suppressing drugs for breast cancer or given chemotherapy or pelvic radiation for other cancers and women whose ovaries were surgically removed.

With women now living more than a third of their lives past menopause and more and more surviving cancer, sexual problems linked to estrogen decline are increasingly common.

Yet, only about one-quarter of women with vaginal pain ever report the problem to a medical professional. And those who do speak up are often told — incorrectly — that nothing can be done and that they must learn to live with the pain.

Among the many patients treated by Dr. Deborah Coady, a New York gynecologist and author, with Nancy Fish, of "Healing Painful Sex," are those told by other doctors that "It's all in your head," "You just need to relax," "There must be something wrong in your relationship" or "There's nothing physically wrong with you." One doctor even suggested that a patient tell her boyfriend to get another girlfriend.

Small wonder that so many women with vaginal pain feel isolated and ashamed and think of themselves as damaged goods, said Fish, a psychotherapist and a sexual pain patient herself.

"Whatever your age, when you have sexual pain it affects your whole sense of self," she said in an interview. "Regardless of the cause, for many women it can be a life-altering condition."

She urged women not to be embarrassed and to start talking about it as a critical first step toward making effective treatment more widely available.

The hormone connection

As women approach menopause, estrogen production declines, then stops completely, or nearly so, as the ovaries shut down.

When ovaries are surgically removed before menopause, or when premenopausal women with cancer are treated with estrogen-suppressing drugs or with pelvic radiation, the loss of estrogen is abrupt. Often women are not prepared for the consequences.

Doctors focused on treating cancer are unlikely to consider the effects on a woman's sexuality. But Coady said there is a new quasi-specialty called "oncosexology" that is trying to educate oncologists about how to handle this side effect more effectively.

Vaginal atrophy, also known as atrophic vaginitis, involves a thinning, drying and inflammation of the walls of the vagina from a loss of estrogen. The symptoms may include dryness and burning; a shortening of the vaginal canal; urinary burning, urgency and incontinence; and frequent urinary tract infections.

"As estrogen declines, there are huge environmental changes in the vagina," Coady said in an interview. "Cells on the surface of the vaginal canal don't mature, resulting in thin skin."

The vagina becomes less acidic, she added. The good bacteria that normally predominate, lactobacilli, disappear and are often replaced by harmful bacteria and fungi. The result may be a yellowish secretion that can be irritating. The vaginal lining splits easily, too, which can lead to infections.

When vaginal walls are fragile, penetration and thrusting during intercourse, if even possible, can cause tiny tears. When sex hurts, a woman may try to avoid intimacy altogether, which can jeopardize an existing relationship or keep her from entering a new one.

"Ironically," Coady said, "women who are fit and lean tend to suffer more from a loss of ovarian function, because women with a lot of fat cells make more estrogen in their body fat."

The effects of hormone loss are also greater among women who smoke and those who have never given birth vaginally.

Treatment is possible

Coady urges women with sexual pain not to give up, no matter how old they are or how many doctors may have told them that nothing can be done to relieve their discomfort. It is important not to delay treatment: The longer sexual pain persists, the more likely it is to result in nerve pain and dysfunction of the pelvic floor, making the problem still harder to treat.

Patience is also important. It can take weeks or even months to achieve the full benefits of effective treatment, which may involve several complementary approaches.

Local treatments found to be helpful include a vaginal estrogen ring (Estring) that is replaced every three months; an estrogen tablet (Vagifem) used daily for two weeks, then twice a week thereafter; or vaginal estrogen cream (Estrace, Premarin and the like) applied daily for a few weeks, then twice a week thereafter. Used in small amounts as directed, these result in very little bodywide absorption of estrogen. Estriol, a less potent estrogen, is considered safe for women who have had an estrogen-sensitive cancer.

But insertion of an estrogen into the vagina does little to relieve "entry pain with penetration," Coady said, so treating the vaginal opening is critical as well.

Whether vaginal discomfort is mild or severe, regular use of an over-the-counter lubricant like K-Y Jelly (by both partners) or a vaginal moisturizer like Replens can help make sex more pleasurable. Coady has found that applying a coating of natural oils like vitamin E or safflower, coconut or olive oil three or four times a day for a month or two can hydrate the vulvar skin, strengthen it and even heal fissures.

These oils are even more effective when combined with small amounts of pharmacy-compounded estriol and testosterone, she said.

Physical therapy can also be an important component of treatment. Sexual pain often involves changes below the surface: shortened connective tissues and weakened muscles that contribute to sexual discomfort. Coady said use of a dilator or vibrator can increase blood flow to the vaginal area, and a soft doughnut ring at the vaginal opening can elongate the vaginal canal.

In addition, exercises like yoga, Pilates, qigong and others that strengthen the pelvic floor and increase flexibility can be very helpful, Coady said.

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