When things go dry down south

I am sorry to report, as a number of you already know, that the problem of mid-life atrophy changes in the genital and urinary tract are a matter of when, not if.  Up to the time of peri-menopause, the mid-cycle hormonal surge of regular menstrual periods provide estrogen, progesterone and testosterone support of the vagina, the bladder and the pelvic floor muscles, all of which are very hormone dependent and responsive tissues.

In the process of these cycles phasing down to a postmenopausal baseline, the accumulative hormonal deficit allows gradual and progressive tissue atrophy to occur.  Sometimes this can occur well before your periods quit. For others, it may be a few years after the menopausal transition before symptoms are readily apparent.  Since they will occur in every woman−to some degree, it is useful to understand the symptoms, which affect three major areas:

  1. Vaginal, where atrophy changes can include:

vaginal dryness, and a lack of lubrication with sexual activity. As atrophy progresses, the normally thicker, more resilient and responsive cell layers become thinner, more easily irritated, and less able to lubricate.

-discomfort with intercourse and/or a lack of responsiveness with sexual activity.  Too much of the ho hum, are we done yet…vs. OMG!, let’s do that again; well, sometime soon, anyway… (remember that?).  With progressive atrophy, blood flow lessens and nerve sensation diminishes; both of which reduce sexual responsiveness.

  1. Urinary function. Because the bladder is right next door to the reproductive tract, and is also very hormone responsive, a number of urinary problems can emerge so gradually that they can sneak up on you, including:

-a loss of elasticity and muscle tone over time that can allow for incontinence; where one can unexpectedly lose urine with laughter or a sneeze, or when taking two stairs at a time.

-more bladder neck sphincter muscle irritability, which gives you the ‘gotta go, gotta go’ urgency feeling.  That requires quicker trips to the loo, not to mention wondering where the heck some of those stores hide their bathrooms…

-changes in the urethra which don’t support the usual healthy bacterial flora, which makes it harder to repel pathogenic ‘bad’ bacteria.  Low grade or outright urinary infections may start to be an issue even in perimenopause; well before periods actually quit.  For more details on this, and additional natural treatment options, see my article on recurrent urinary infections

As one of my patients put it oh-so practically: “while I hope to have sex the rest of my life, I suspect I will be having to pee right up to the last day”.  Barring the need for dialysis, she is spot on with that suspicion.  That is why I typically recommend that women in the peri-menopausal time frame and onward consider using a safe and effective hormone support therapy on a regular basis to also assist their bladder health.

  1. Atrophy also affects the muscles of the pelvic floor. Loss of muscle tone will affect both bladder and bowel function.  One goal with the vaginal therapy we will discuss is to improve pelvic muscle tone, restore natural elimination function and assist sexual response.

Restorative therapy for genitourinary atrophy

To slow, stop and preferably reverse the problems we reviewed above, we need to address the underlying factors, not just lubricate the symptoms.  There are two general approaches I use to do this.  Both are physician prescribed and can be obtained from most compounding pharmacies.

#1  Local hormonal rehab.  The aim is to prevent or undo pelvic region atrophy with low-dose and ongoing estriol vaginally cream therapy.  While estriol is a less intense version of estrogen than the more potent and commonly used estradiol, it is actually better for vaginally rejuvenation.  Typically, the applied dose works locally and will not change your whole body hormone levels. I usually have my patient use a third of the 2 grams total dose applied to the external genital area, and the other two thirds inserted intra-vaginally at bedtime with an applicator.  Some physicians use a small amount of testosterone vaginally to achieve some of the same benefits. Instead, I typically use a small dose of DHEA with the estriol in the vaginal cream.  The DHEA is a testosterone precursor, and the testosterone metabolized from the DHEA can then be utilized locally as needed to obtain direct tissue support.

This process typically achieves initial benefit over 2-4 weeks to 2-4 months, depending on how much restoration is required.  Sometimes we start more intensively with every other day use, and many times this can be tapered to a once or twice a week maintenance over the first few months.   If you are using a systemic topical or oral hormone support therapy, don’t be fooled into thinking it will meet the pelvic region’s full needs, although it can add somewhat to direct vaginal therapy.  Think of it this way: if you weigh 150 lbs, and the pelvic region at risk is ~1.5 lbs., then that tissue only gets a pro-rated 1%, maybe 2% at most of the topical or oral dose.  I can just hear the pelvic region saying ‘hey, we could use some help down here!  Could we get a little extra?  And that’s where the vaginal cream comes into play.

#2  Reducing inflammation and increasing collagen.  An adjunctive therapy I find useful is a 2 to 4 week course of 0.5% hyaluronic acid in a vaginal cream or suppository.  Hyaluronic acid facilitates tissue healing and collagen repair, as well as enhancing the retention of fluid in the cells to enhance moisturization.  This treatment can accelerate the repair process when atrophy or inflammation symptoms are significant at the onset of therapy.  One can use it every other night, alternating with the estriol for the first 4-6 weeks of the rejuvenation and repair process.

When it comes to rejuvenating things ‘down south’, I can’t count how many times I’ve heard those who made progress with pelvic atrophy problems say: “I didn’t know how bad I was until I got better”.  If you think that could be your story as well, check with a bio-identical capable physician about these treatment options.

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