Understanding VVA

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By Margaret Jaworski

Don’t press pause on your sexual health

Aging gracefully doesn’t mean accepting discomfort or pain as an inevitability. For the most part, we seek and find relief for the aches, twinges and physical manifestations (anti-wrinkle cream, anyone?) that accompany a long life. But when the discomfort or pain happens “down there,” and interferes with intimacy, women are often too embarrassed or self-conscious to speak up.

What we’re talking about is postmenopausal vulvar and vaginal atrophy (VVA), the thinning of the vaginal tissue related to low estrogen. The symptom including dyspareunia (pain with intercourse), vaginal dryness, and irritation can affect sexual activities, personal relationships, and the activities of daily life.

All postmenopausal women will have VVA to some degree, and about half will experience moderate to severe symptoms.

Woman now live 30 years of their lives post-menopause, says Lisa Larkin, M.D.Pretending that VVA is not a disorder that affects millions of women is wrong, says Larkin, who is director of the UC Health Women’s Centerand division director of midlife women’s health and primary care in the Department of Obstetrics and Gynecology at the University of Cincinnati College of Medicine.

The good news is that many treatment options exist, including nonhormonal choices such as over the-counter vaginal lubricants and moisturizers, low-dose vaginal estrogen preparations (creams, tablets, sustained-release estradial ring), oral estrogen, and a new drug, Osphena (ospemifene), approved in February by the Food and Drug Administration for the treatment of dyspareunia, a symptom of menopause-related VVA.

In conjunction with the FDA’s go-ahead, the drug’s maker launched Finding the Words, a consumer campaign aimed at sparking conversation, encouraging women to talk to their doctors about VVA, and, of course, to introduce the drug to women. (Please read the Pain Resource profile of spokespersonVirginia Madsen.)

Silence is not golden
The trouble is that so few women are educated about VVA and dyspareunia in the first place, says Ricki Pollycove, M.D., M.S.

A gynecologist at Pacific Medical Center in San Francisco and a paid spokesperson for the awareness campaign, Pollycovepoints out that if a woman already has a problem with vaginal pain, “VVA can make it worse because the cushioning capacity of the vaginal cells is diminished. And we know that many pain disorders are due to over activation of vulnerable receptor nerves.”

Pollycove doesn’t let health care practitioners off the hook, either. “Doctors have to be willing and prepared to discuss this condition during routine office visits,” she says.

Treatment
It’s very important to have a thorough exam, including a health history, with a knowledgeable health care professional to rule out other causes of vaginal dryness and irritation. If VVA is the diagnosis, you and your doctor can discuss the available options given your health and sexual activity.

“Just asthere are women who go through menopause and don’t know what all the fuss is about, some women do just fine with over-the-counter vaginal moisturizers and lubricants, and never require other treatment,” Larkin says. “But in my daily practice, I see many patients that are having an awful time and need help that goes beyond lubricants and moisturizers.”

“Osphena is a good option for a certain group of patients who otherwise might go untreated because they absolutely won’t or can’t take estrogenand don’t like to use creams or rings,” Larkin says.

Osphena is not an estrogen but belongs to a class of drugs known as selective estrogen receptor modulators (SERM). In clinical trials, ospemifene was shown to make vaginal tissue thicker and less fragile, resulting in a reduction in the amount of pain women experience with sexual intercourse. It is a medication in the same family as tamoxifen, which is used in breast cancer treatment and prevention protocols.

And there are risks including clotting and stroke.

“It’s a small risk, but a risk nonetheless,” Larkin says.

In clinical trials, ospemifene also increased the incidence of hot flashes. “It’s not desirable to fix one problem by creating another problem,” she says. For that reason, Larkin says, the best candidate for Osphena is a woman in her late 50s who no longer has hot flashes but is experiencing dryness, irritation, and pain with intercourse.

“For most women, menopausal symptoms such as hot flashes resolve themselves after a few years, but that’s not the case with VVA. Vaginal dryness is the one thing that gets worse with time,” Larkin says.

Because risk factors and personal needs change over time, she is vigilant in monitoring patients on any type of estrogen or other oral medication for VVA.

“If a patient’s circumstances change, if she is no longer sexually active, has developed risk factors [such as hypertension or high cholesterol], then I’d discuss her risks with her and rethink whether or not she needs to be on estrogen of any kind or Osphena,” Larkin says.

If you’re a woman approaching menopause, in menopause, or beyond it and experiencing problems, speak up and speak out. Your sexual health is an important part of your life.

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