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Ask The Expert: Advances in Gynecological Care After Menopause

Dr. Carolynn Young headshot Dr. Carolynn Young

For women around the world, the word “menopause” can elicit feelings of excitement as well as dread. Defined as the absence of menstrual periods for 12 months, menopause can bring joy to women who no longer want to deal with menstruation. For a large number of women, however, menopause also brings an entirely new set of symptoms and conditions, some of which can feel debilitating. Dr. Carolynn Young, a board certified obstetrician and gynecologist and the former chair of gynecology at Suburban Hospital, explains why women don’t have to suffer in silence. Questions were submitted privately from the public and through Suburban Hospital’s Facebook page. Additional answers were provided by her colleague Dr. Astrid von Walker Gonzalez.

What are some of the physical changes that will impact my gynecological health after menopause?

Eighty percent of women experience hot flashes in menopause. Sleep disturbance is also a big issue, with between 30 percent and 45 percent of women complaining about difficulty sleeping. Other symptoms include depression and a decrease in sex drive. Some women experience cognitive changes such as memory loss or difficulty concentrating. Women also complain of joint pain or stiffness, although it’s unclear whether joint pain is related to a deficiency in estrogen or whether there is a rheumatologic issue. While all of these symptoms are associated with menopause, they can also occur during the perimenopausal transition, the years leading up to menopause.

Is there anything a woman can take to reduce hot flashes and how long will these last?

While hot flashes usually subside within four to five years, for some they can persist for 10 years or more. In general, the length of time hot flashes will last is unpredictable, but there have been reported cases of women who have hot flashes into their mid-60s. The length is dependent on if the patient was on hormone replacement therapy or not.

Natural ways to combat hot flashes are:

  1. Dressing in layers so you can just remove some clothing when a hot flash is present
  2. Increasing your level of exercise
  3. Eating more sources of natural estrogen, which are found in soy products such as soy beans and tofu.
  4. Over-the-counter remedies like Estroven and Remifemin may work for some patients. However, you should be cautious about the use of these products if you have a history of breast cancer.

What is vaginal atrophy and what are the symptoms of this condition?

Many women suffer from vaginal atrophy after menopause. This occurs when a reduction in estrogen results in the thinning and drying of the vaginal walls. Symptoms include vaginal dryness, burning, itching or irritation. As a result of the decrease in vaginal lubrication, some women also experience pain with intercourse. If this pain makes them want to abstain from having intercourse, the vagina can actually become shorter or narrower so when they do try to have intercourse, it hurts even more.

Because the bladder has estrogen receptors, a decrease in estrogen level can also lead to bladder changes. These include urinary frequency, having to get up during the night to urinate, some urinary incontinence or urgency, and burning with urination. When we treat vaginal atrophy, many of those bladder symptoms will improve or resolve.

How many women experience vaginal atrophy?

Nearly 50 percent of postmenopausal women will experience symptoms of vaginal atrophy and 50 percent of those women will develop it within three years of menopause. What is most unfortunate is the fact that as many as 70 percent of women with vaginal atrophy do not discuss their symptoms with their healthcare provider. They believe their symptoms are just a normal and necessary part of the aging process.

When should I see my doctor?

If you are experiencing any symptoms that are adversely affecting your quality of life, talk to your doctor. You may have tried over-the-counter lubricants but have found no relief for painful intercourse, or you may not even be sexually active but the feeling of vaginal dryness is bothering you. It’s important to know that there are treatment options available.

How is vaginal atrophy diagnosed?

Vaginal atrophy is diagnosed by a physical exam. We look in the vagina to see if the vaginal mucosa appears thin. We determine if there is a loss of elasticity in the vagina, with shortening and narrowing of the vaginal canal. We can also check the vaginal pH level. A healthy vagina is acidic; the pH level will tell us if the vagina has the healthy glycogen production that will keep it acidic. We also look for the presence of yeast or bacterial overgrowth, both of which can cause the same symptoms as vaginal atrophy. Yeast or bacterial overgrowth can be easily treated.

Some women with vaginal atrophy actually experience a yellow discharge instead of vaginal dryness. These increased secretions can also be seen on exam. While the vaginas of most women with atrophy appear thin and dry, sometimes you can have a lot of bright yellow discharge.

What are the treatment options for vaginal atrophy?

Traditional treatment includes medication. Systemic estrogen therapy, also known as hormone replacement therapy, comes in the form of a pill, patch, gel or spray. There is also a vaginal ring, which puts estrogen directly in the vagina. Most women who use a vaginal ring have great results. Some women prefer using a patch or gel that goes on your inner thigh or upper arm, although the dosage of estrogen in these forms of treatment may not be high enough to positively affect the vagina.

For those women who do not want to use systemic estrogen therapy, topical estrogen is also available as a cream, a vaginally inserted tablet, or a vaginal ring. This ring is different from the ring used with systemic estrogen therapy, as it only works in the vagina and there is very minimal absorption of estrogen into the bloodstream. The vaginal tablet also has minimal systemic absorption. Both of these treatments are considered very safe. The cream does have a very small amount of systemic absorption even though it’s placed vaginally. Overall, all of the medication options are very effective and most women who use them report adequate relief of their vaginal atrophy symptoms.

There is a new treatment for vaginal dryness/pain with intercourse that is an oral medication and it works as an estrogen on some tissues in the body and as an anti-estrogen on other tissues. It can take up to 12 weeks to work and it does have some side effects that will limit its use.

Are there any treatment options that don’t involve medication?

There is a new treatment that is currently the only option that does not involve medication. It is called fractional CO2 (carbon dioxide) laser treatment and it is now being used on the vagina and vulva. This laser therapy is an exciting treatment option, especially for women who cannot or do not want to use estrogen medication therapy. This includes breast or uterine cancer survivors — any woman with a history of estrogen-dependent cancer — or women who just don’t want to be exposed to estrogen. Some women also don’t want to deal with the nuisance of having to place something in their vaginas, whether it’s the messiness of a cream or inserting a tablet twice a week or the vaginal ring every three months.

Since laser therapy for vaginal atrophy was invented in Italy three years ago, more than 20,000 women worldwide have been treated with no complications. This treatment has been available in the U.S. since the beginning of 2015.

Are there any women who are not good candidates for laser treatment?

There are women who cannot receive this therapy. They include those who have had pelvic radiation or a pelvic prolapse surgical repair with mesh. (This does not include women who received the sling for urinary stress incontinence.) Anyone with keloids shouldn’t have laser treatment, nor should those who have poor tissue healing due to the use of immunosuppressants. Women with any vaginal or cervical lesions that have not been diagnosed, those with an active vaginal or vulvar infection, and those who have significant pelvic organ prolapse are also not candidates for laser treatment.

What does laser therapy entail and what results can I expect?

Laser treatment is performed in the office setting. We do three treatments six weeks apart. Each treatment takes only three or four minutes and there is no pain. While a numbing cream is used on the vulva, we can laser the vagina without any anesthesia. The laser makes tiny micro-perforations in the vagina and vulva. The tissue reacts to the laser energy by causing a proliferation of collagen, resulting in a very thick, healthy vagina that produces a lot of moisture.

Within two weeks after the first treatment, a number of patients notice an increase in lubrication and less pain with intercourse. After all three treatments, patients are reporting fantastic results. Many women who had also complained about urinary frequency and getting up at night to urinate find that these symptoms have improved as well. This is a wonderful side effect of the treatment. Just as exciting is the fact that the results of laser therapy are durable. One to two years after the initial three treatments, about 50 percent of those treated will need one booster treatment while the other 50 percent are still doing great.

While laser therapy is a revolutionary new treatment option, it is not yet covered by insurance. Talk to your doctor about whether this treatment is right for you and the costs involved.

Is there anything I can do to try to avoid vaginal atrophy?

Regular intercourse keeps the vagina longer and the mucosa healthier. Women who engage in regular intercourse have a lower risk of developing vaginal atrophy.

About Dr. Carolynn Young

Dr. Carolynn Young obtained her medical degree from the Vanderbilt University School of Medicine, where she was inducted into the Alpha Omega Alpha Honor Society. She then attended Eastern Virginia Medical School for a residency in OB/GYN. Dr. Young enjoys educating women about advances in the field of gynecology and minimally invasive gynecologic surgery. She has a special interest in the treatment of uterine fibroids, abnormal bleeding, contraception, adolescent gynecology and abnormal pap smears. Learn more about Dr. Young by visiting www.rockvillegynecology.com .

Dr. Young’s office
Rockville Gynecology
15204 Omega Drive, Suite 200
Rockville, MD 20850
301-330-7007