Estrogen is a hormone that maintains the moisture of the vulva and vagina by increasing water retention on the cell’s surfaces. Ovaries produce estrogen before menopause, but there are other sources of estrogen production in the body as well. When estrogen levels are low, the vulva and vagina can become fragile and painful. Some people do not have symptoms, but other people have dryness, irritation, rawness, painful sexual activity, and burning of the opening to the vagina. Peripheral fat cells produce estrogen, so people who are thin are at higher risk for developing atrophic vaginitis over time.
Atrophic vaginitis is easily remedied by the use of topical estrogens. Since it is a topical preparation, there are very few systemic side effects as very little estrogen is absorbed throughout the rest of the body. Estrogen can be delivered via topical creams, tablets inserted into the vagina, vaginal rings, skin patches or oral pills.
Initially, higher doses of estrogen will be recommended during the first two weeks in order to reach a more normal level of estrogen, after that, use is generally limited to 2-3 times per week. Increases to estrogen can increase vaginal moisture and thus discharge. This discharge is not a sign of infection but can be uncomfortable due to the change in environment. Yeast infections are more common in people with higher estrogen levels, so often I will prescribe fluconazole pills to take around the time of initiation of estrogen.
Other non-hormonal based options for atrophy and vaginal dryness include vaginal moisturizers and lubricants. These are typically used up to 1-3x weekly to provide additional moisture to the vagina. Ideally, lubricants or moisturizers should have a low osmolality (less than 1,200 mOsm/kg) in order to prevent irritation to the vaginal and vulval tissues and decrease susceptibility to infections.
Things to consider when looking at lubricants and moisturizers:
1. Try to avoid glycerin as this may contribute to an increased number of vaginal infections.
2. Parabens are weakly estrogenic and have been included as preservatives in some lubricants and moisturizing products. There has been no direct link between parabens and cancer but this is something to keep in mind if you have a history of breast cancer. Parabens and other ingredients such as propylene glycol, quaternium, and fragrance can sometimes cause allergic reactions in some patients.
3. Trial and error is the best way to find the vaginal moisturizer that works for you.