Pain with Sex After Menopause

Posted by on Jan 31, 2019

  With the menopause transition comes a change in estrogen levels. That change affects just about EVERYTHING, including sex. Estrogen is responsible for keeping the tissue of the vagina moist and well lubricated. It keeps this tissue plump and healthy and even helps keep the good bacteria in the vagina healthy! When estrogen levels decline, the tissue in the vagina can become dry, thin, less lubricated and less elastic, all of which can cause sex to feel painful or cause a burning or tearing sensation. For some, this pain can be significant enough to deter all interest in sexual activity. Fortunately, there are many things that can be done to protect this tissue and to keep sex (touch and/or penetration) comfortable. Vaginal moisturizers and lubricants are the first options to consider but the two are quite different from each other.  We can think of vaginal moisturizer similarly to lotion that we use on the rest of our bodies when we have dry skin. The purpose of a vaginal moisturizer is simply to provide moisture to vaginal tissue and should be used on a regular, even daily basis. Lubricants are used to increase pleasure and decrease friction with sexual activity. They are typically made in a base of water, oil, or silicone but some brands can have some less desirable additives such as parabens and petroleum so make sure to read the labels, because there may be some undesirable short and long term effects of these two ingredients.   Ideally, your lubricant will have a pH that is similar to that of the vagina helping to keep your vagina healthy and balanced.  If vaginal moisturizers and lubricants are just not doing the job, we have other options!  Lose-dose, select hormones applied directly to the vagina and/or vulva can often provide substantial benefit to the local tissue.   Research strongly supports the use of either vaginal estrogen or DHEA (Dehydroepiandrosterone) low-dose hormones for the treatment of vaginal dryness. Fortunately, very little of these low-dose hormones are absorbed into the blood stream, which makes them a good option for a wide range of women. There are even vaginal estrogen products and vaginal DHEA products that are considered safe for some breast/endometrial/ovarian cancer patients. However, if you have a history of breast or other hormone sensitive cancer it is always best to speak with your doctor prior to attempting any hormone therapy. It is also important to note that there are numerous methods by which these hormones can be delivered including: suppositories (large and small), creams, tablets, and rings. Having this variety of options allows clinicians to individualize the treatment to find the best delivery method for you. Finally, regular sexual activity can...

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Yeast Vaginitis (and boric acid)

Posted by on Dec 6, 2018

Roughly 75% of reproductive aged females will experience at least one vaginal yeast infection (vulvovaginal candidiasis or VVC), with half of them developing a second episode at some point.  Additionally, between 5-9% of these women will go on to develop recurrent vulvovaginal candidiasis, meaning numerous episodes over the course of a year. Vulvovaginal candidiasis is clearly noted as one of the most common vaginal infections experienced by women of childbearing age with symptoms that are very familiar to many of us. Symptoms of VVC often include vaginal and vulvar itching, burning, irritation, pain with intercourse, and a thick, white discharge. Unfortunately, symptoms of VVC often overlap with other vulvovaginal conditions and thus are often assumed to be VVC when in fact they are a constellation of symptoms attributable to another condition. Furthermore, it is not uncommon for individuals to have more than one microbe responsible for the upset within her vaginal ecosystem. For these reasons it is important for women experiencing vaginal symptoms to be evaluated by a provider so that objective testing may be used to decipher the precise cause of imbalance. Such testing may include vaginal pH evaluation, microscopy, culture, or testing for fungal DNA. There are numerous factors that play a role in the development of recurrent VVC. For example, an increased estrogenic state such as that seen in pregnancy or achieved with use of oral contraceptive pills may increase the risk of a patient developing VVC. The use of antibiotic medications should be considered as a potential risk factor for a woman developing VVC as it likely alters the vaginal microbiota. While I am in no way advocating against the above listed medications, I am encouraging a heightened awareness of VVC in persons with these conditions or using these medications. Additionally, persons with compromised immune systems are often at heightened risk for the development of recurrent VVC. Although most women with VVC do not have the following conditions, individuals who have been diagnosed with diabetes, human immunodeficiency virus (HIV), or who routinely take glucocorticoids or immune suppressing agents may experience recurrent episodes of VVC Conventional treatment of VVC generally includes an anti-fungal agent, often one that falls into the azole class of medications, such as oral fluconazole or topical miconazole. Although there are numerous additional options within the azole class, additional classes of antifungal medications are few.  These limited treatment options have presented a challenge, as there are increasing numbers of cases of azole resistant candida. Candida albicans is the predominant culprit with VVC, however, several other species of yeast may contribute to symptoms. Knowledge of the distinct species may be helpful in selection of treatment as not all species of candida are susceptible to...

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Vaginal Infections

Posted by on Apr 23, 2018

  Vaginal discharge? Vaginal irritation? Odor? What to do? Vaginal infections are exceedingly common. In fact, they are so common that the majority of women will experience at least one in her lifetime. Vaginitis complaints are responsible for roughly 10% of doctor visits each year, amounting to nearly $10 million in annual costs.   Outlined below are the major causes of vaginal infections, associated complications, and how they are identified and treated.   The majority of vaginitis cases in women of childbearing age can be attributed to bacterial vaginosis (BV), yeast vaginitis, and trichomoniasis.   Bacterial vaginosis (BV) is the most common cause of infectious vaginitis, and is characterized by white, thin discharge with a fishy odor, and elevated vaginal pH that is often attributed to an imbalance of normal vaginal bacteria. Some women note symptoms are worse after intercourse or menses, while others experience no symptoms at all. It is important to treat symptomatic BV because this disruption in vaginal flora has been shown to increase risk for acquiring and transmitting sexually transmitted infections (STIs). Additionally, BV can lead to poor pregnancy outcomes. Your provider can diagnose this condition after doing a pelvic exam and collecting a sample of vaginal fluid. Conventional treatment primarily includes oral or vaginal antibiotics. Natural agents such as boric acid suppositories, vitamin C suppositories, and very specific species of probiotics may be sufficient in some cases or may augment conventional treatment in other cases. Unfortunately, BV recurs in as many as 58% of women who were previously treated and experienced resolution. For these cases we can look to other factors that may influence the existence of BV like biofilms that can harbor bacteria, preventing adequate exposure to antibiotics. Additionally, douching, low vitamin D status, smoking, diet, and stress may play a role in development and recurrence of BV.   Yeast vaginitis is also known as vulvovaginal candidiasis (VVC) and can cause symptoms of itching, burning, pain with intercourse, red and inflamed tissue, along with a yellow-white “cottage cheese” discharge. The most common culprits are Candida albicans (80–90 % of symptomatic cases), Candida glabrata (2–5 %), and Candida krusei (1-2 %).  VVC is one of the most common vaginal infections – responsible for 40-50 % of all vaginal infections. About 75% of reproductive aged women will experience at least one episode of VVC. Unfortunately, up to 50% of these women will develop a second infection of VVC and up to 5% will become recurrent cases.  Conventional treatment includes oral or local antifungal and restoration of the vaginal microbiota. In addition to conventional treatments, Naturopathic physicians may use botanical/nutraceutical antifungal agents to re-establish normal vaginal flora, as well as address gastrointestinal function and flora and...

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