Persistent vaginal dryness and itching in menopause. What can I do?

Ask Dr. Jen

I’ve been having chronic issues (dryness, itchiness, UTI, feeling like I have a UTI, etc) and wanted to know if you had heard of a procedure called Lipogems, which is injecting autologous and micro fragmented adipose tissue to relieve symptoms. There is an NIH study and case results that sound promising. Application of estradiol cream, and other vaginal moisturizers aren’t effective.

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Short Take

The procedure is essentially taking a concoction of fat and treating it to remove cellular debris, injecting it back into vaginal tissues and then, through the miracle of stem cells and other bioactive elements, the tissues affected by menopause are rejuvenated. The studies are low quality and the hypothesis behind how it is supposed to work isn’t clear, so I would advise against it. 

Go On…

There are  variety of injections promoted as wonder therapies for vaginas in menopause. None are FDA approved or cleared for this purpose and all are recommended against by experts and the major medical societies. The published data for this procedure is very low quality. I found a case series and a small observational study, both with issues.

The original case series makes some, um, interesting claims. Apparently the fat injections can do all sorts of things…

trophic, mitogenic, anti-scarring, anti-apoptotic, immunomodulatory, and anti-microbial actions, produced by a large amount of bioactive elements, growth factors and cytokines, these cells “sense” and “signal” changes in the microenvironment where they reside. 

This seems best translated as, “Through the power of stem cell magic this is going to fix everything. We don’t yet know how, but there is cool stuff here. You’ll see!”

Given the predatory history of procedures in women’s health, we need quality data about safety and how well a procedure works to make recommendations. And we do not have that here. We don’t even really have a solid hypothesis. The idea that injections of “bioactive elements” can not just reverse the vaginal symptoms of menopause, but that they start working at 2 weeks and are still be going strong at 12 weeks as claimed in one of the papers is indeed a remarkable claim. And remarkable claims require remarkable proof.

I understand when you are suffering that these kinds of claims or reports are appealing, and the people who promote these injections known that only too well. It’s very disheartening to see these kinds of therapies continually popping up.

In my opinion, it’s unethical to offer this procedure for symptoms of menopause outside of a well-done clinical trial that includes an appropriate sham (placebo procedure) arm, as we know that sham/placebo therapies also often result in significant improvement.

As it stands, you couldn’t pay me enough to have this procedure done on myself or to get trained to do it. 

OK, but I have untreated symptoms

There are many reasons people still have symptoms described above in menopause despite using vaginal estrogen, so let’s run through the scenarios so hopefully you can get some help.

Dose of estrogen is too low

Vaginal estrogen doses vary a lot, and some people who are using ultra low doses in the form of the 4 mcg or 10 mcg vaginal suppositories or tablets may simply not be getting enough estrogen. So one option is to consider increasing the dose delivered by using the ring (Estring) or vaginal estrogen (estradiol or Premarin) cream. Also, it’s important to dose the therapy adequately. For example, if the product is meant to be used twice a week, and you are only using it once a week, that may not be enough. 

If the estrogen just isn’t cutting it, another option is vaginal DHEA (sold as Prasterone). 

Also, it can take 6-8 weeks to get the full effect when you start one of these therapies and if you stop, the symptoms will return. That doesn’t mean it’s ineffective, it just means you can’t stop it. 

Only treating vagina and not vaginal opening

The majority of the estrogen receptors are in the lower third of the vagina, so sometimes the tablets, suppositories and even the ring don’t deliver enough estrogen at the opening. This is especially important as there are more nerve endings and pain receptors at the vaginal opening, so dryness here is extra irritating. So when the dryness and itchiness is at the vaginal opening or labia, that’s another reason to consider estrogen cream, because you can also apply a pea sized amount to the labia minora and vaginal opening as well as inserting it vaginally. And remember, it will take 6-8 weeks to take full effect.

Do you have a yeast infection?

While less common after menopause, yeast infections can happen, especially for people using vaginal estrogen. They can produce a sensation of dryness, and so I recommend a vaginal culture for yeast, as this is the best test. It is a special culture called a mycology or fungal culture and then if positive, treat accordingly. 

Do you have pelvic floor muscle spasm?

These are the muscles that wrap around the bladder, vagina and rectum. When they are tight they can make it feel as if you have a UTI when you don’t and they can also cause a sensation of itchiness and dryness for some. They can also cause pain with sex. 

If you don’t have a UTI, I’d recommend getting your pelvic floor evaluated by a pelvic floor physical therapist. 

If the itching isn’t bad enough to cause scratching, I’d say this is the most likely cause of the symptoms based on the limited information.

Do you have a skin condition?

There are a couple of skin conditions that can produce these symptoms if they are located at the vaginal opening or on the vulva. One is lichen simplex chronicus, which is an eczema-like condition and the other is lichen sclerosus, an autoimmune skin condition. The first line treatment for both is potent topical steroids, but topical estrogen cream can also be helpful (as a co treatment). A gynecologist who specializes in the vulva should be able to help here.

Lichen planus is an autoimmune condition that affects the inside of the vagina, and should be considered if the symptoms are deeper in the vagina.

Some other tips and tricks

Make sure you are not using soap on the vulva as it’s drying, only use a cleanser. I recommend CeraVe gentle foaming facial cleanser, but any gentle facial cleanser should be fine (skip the ones with active ingredients).

Are you itchy enough that you want to scratch or are having a hard time not scratching? In this situation it’s almost always yeast or lichen simplex chronicus. 

Make sure you aren’t using any products that irritate the vulva. If you have incontinence, use incontinence pads or garments, not menstrual pads, which can’t absorb the volume, leaving the wet pad to irritate the skin. And no wipes, they are filled with irritants and absolutely no Vagisil, which is the worst product ever. It has benzocaine and that causes a skin reaction that can itch, or even be very painful, for about 10% or so of people. Just say no.

Dryness makes itch worse, so consider using a moisturizer for the vulva is the issue is here. Coconut oil actually works well, and this is a great option if the itch is at the vaginal opening as getting some inside in the vagina isn't a big deal. If the itch is outside on the vulva (think labia majora or between the labia majora and minora) then Vaseline is a great option.

Consider a different vaginal moisturizer, for example if you are using water based, try a silicone based or a a hyaluronic acid based product.

There are other less common things that can cause these symptoms, but running through this list is how I would get started in the office. Keep in mind sometimes it can be two things, for example low estrogen and pelvic floor muscle spasm. 

Hopefully this is enough information to help with those persistent symptoms. And there is more in detail about each condition in my book, The Vagina Bible.

What questions do you have?