Use It or Lose It: Fact or Fiction About Vaginal Lubrication?

If you’ve read enough of my past blogs, you’d think the whole world is experiencing dry, painful intercourse — and that without the benefit of a great lube, a local vaginal estrogen, ospemifene (a non-estrogen oral medication), or a CO2 laser treatment, women are doomed to a destiny of sandpaper sex or no sex. But that’s not the case.

Before menopause, the majority of women don’t require anything other than the occasional lubricant. Post-menopause, only about half of women have lubrication trouble.

So what separates the two groups: Good genes, good diet, or good luck?

When it comes to vaginal elasticity and lubrication, a number of factors besides estrogen and age have a role. Certain medications have a negative impact, for example, and women who’ve never had a vaginal delivery are more likely to have vaginal tissue that becomes dry. Other contributors to a lack of lubrication are inadequate blood flow to the vaginal walls due to the normal aging process, a medical problem such as diabetes, and cancer treatment.

Another factor beside age, medical problems, and luck is the value of regular use.

Vaginal Lubrication and Regular Intercourse

Regular stimulation of vaginal tissue helps maintain blood flow, which in turn increases lubrication and elasticity. And that’s where “use it or lose it” comes into play.

Women who have had a long sexual hiatus are more likely to experience vaginal dryness than women who are regularly having intercourse.

So what’s a woman to do when she’s between partners, or has a partner who’s out of business, to keep her tissue from drying up?

In many cases, the changes destined to occur from lack of use are preventable. You may have to get creative and be consistent about stimulating blood flow. Regularly inserting a dildo or a vibrator should help maintain vaginal lubrication and elasticity. And just like going to the gym, you will probably enjoy it once you get started!

Of course, if your vaginal tissue is already very thin and dry, a little repair work may be in order in the form of a prescription product like vaginal estrogen. One of the most common questions I get when I prescribe a local vaginal estrogen is, “How long will this treatment be necessary?”

In general, my answer is “forever,” because once the treatment is discontinued, the vagina will become thin and dry again. But in my experience, for many women who have had a long hiatus, a local vaginal estrogen repairs the situation and they maintain vaginal elasticity by regular stimulation — they don’t need to continue using a prescription.

So if you have no pain, but alas, no partner, stimulate with a device to keep things good to go. Use it or lose it.

Buyer Beware: "Bioidentical" Hormone Myths

by Lauren Streicher, MD

Frequently, patients ask if I prescribe “bioidentical” hormones. It’s a good question, but unfortunately, the answer is not a quick one. Like many  phrases, “bioidentical” means different things to different people. Generally, however, most women inquiring about bioidentical hormones are referring to compounded hormones that are advertised as being safer and better than FDA-approved estrogen and progestogens distributed by commercial pharmaceutical companies.

The North  American Menopause Society (NAMS) recently conducted a survey of 3725 hormone users  to determine the extent and differences between commercial compounded hormone therapy and compounded hormone therapy. Roughly one of four women who use hormone therapy are using compounded hormone therapy however  most are unaware that compounded hormones have not been evaluated or approved by the FDA .  Most are unaware that compounded hormones have risks in addition to benefits. 

Many promoters of compounded hormones claim that their products reverse aging, enhance sex, prevent cancer and, unlike FDA-approved commercial hormones, have no risks or side effects. It all sounds pretty good. But like most things that sound too good to be true, it’s important to separate fact from the myths propagated by clever marketing. 



Myth #1: “Bioidentical Hormones Are Natural.”

The only thing that is natural is to drink the horse urine or eat the soy plant (both are used in the manufacturing of hormones). All plant-derived hormone preparations, whether they come from a compounding pharmacy or a large commercial pharmacy, require a chemical process to synthesize the final product, which can then be put into a cream, a spray, a patch or a pill.

Promoters of compounded plant-derived hormones use the terms “natural” and “bioidentical” because it is appealing to consumers and implies that it is not synthetic.

Myth #2: “Compounded Bioidentical Hormones Are Identical to the Hormones in Our Bodies.”

Plant-derived estrogen from soybeans is molecularly very similar, but not identical to human hormones. That’s why I prefer the term “bio-mimetic” to “bioidentical.”

Furthermore, what you get from the compounding pharmacy (where a compounding pharmacist custom mixes drugs to fit the unique needs of a patient) is not “more human-like” than what you get in an FDA-approved product. In fact, you are actually getting the IDENTICAL estradiol molecule whether you get your hormones from a compounding pharmacy or your mega-pharmacy.

How can that be? This is the interesting part. Compounding pharmacies don’t manufacture hormones – they just mix them. Manufacturing factories are the ones that extract estrogen from plants, synthesize it to a useable form, and then sell the same active ingredients to both commercial pharmaceutical companies and compounding pharmacies. It is then that the active ingredient is used to make lotions, pills, sprays or patches.

It’s basically all the same stuff. In fact, many compounding pharmacies mass produce hormone preparations that are copies of those produced commercially.

Myth #3: “Since Compounded Bioidentical Hormones Are Natural, They are Safer Than Other Hormones.”

First of all, “natural” does not equal “safer.” We can all name many things that are natural, but hardly safe. Arsenic comes to mind. But, in any case, I’ve already dispelled the “natural myth” (see Myth #1).

Let’s forget the word natural and ask if compounded hormones are safer than FDA-approved commercial hormones.

Since compounded alternatives to FDA-approved estrogen and progestogen formulations have the same active ingredient (see Myth #2), they obviously are going to have the same benefits, and the same safety concerns. But unlike commercial hormones, the distributors and promoters of compounded hormones deny these risks. And that’s really misleading. So, how do they get away with it?

Since the FDA does not regulate compounding pharmacies, they can make whatever claims they want. So, they tell women what they want to hear – namely that compounded bioidentical hormones have fewer risks, fewer side effects, and are more effective than standard hormones even though there is no scientific evidence to prove that claim.

While women generally distrust the pharmaceutical industry – which is legally obligated to back up their claims, does testing, and reports all safety risks and negative findings – the general population seems to have little problem placing their trust in companies that have no such efficacy or safety standards. This combined with aggressive advertising and marketing has resulted in women believing that compounded products are safer than standard products.

It’s pretty scary to think that millions of women are using prescription drugs that have never gone through a new drug approval process to substantiate safety, prove efficacy, and ensure quality.

Since it is the same active ingredient, what’s the problem? 

It’s the dosages and protocols, which are commonly recommended, that have never been shown to be safe, much less safer or more effective than conventional prescription hormone products. I just saw a woman who was essentially going bald because of sky high levels of testosterone in a pellet that was injected into her hip. Transdermal progestogens from a compounding pharmacy are particularly  dangerous since there is no evidence that they prevent the lining of the uterus from developing pre-cancerous or cancerous cells. And in fact, the survey  recently published by NAMS  showed  there were 4 cases of endometrial cancer in the group using compounded hormone therapy compared to zero cases of endometrial cancer in the group using commercial products.  No surprise since only oral progestogens have been proven to offer that protection.

So, back to the original question: Do I prescribe bioidentical hormones? I prescribe FDA-approved “bio-mimetic” plant-derived estrogen, produced and distributed by companies that are obligated to tell you not only the benefits, but potential risks as well.  I prescribe products made by companies that adhere to strict protocols to assure purity of the product  and consistency of dosage.   I  do use compounding pharmacies when I need a product that is not available commercially but   I then inform my patient  of all known risks and benefits.

 One last added bonus to commercially available products is that your insurance company will likely cover your prescription.. The non-FDA approved compounded versions will require you to open not only your trust, but also your checkbook. 

Edited Oct 22, 2015  Originally posted  on 11/09/2011

Busting 5 Hormone Replacement Therapy Myths

By Lauren Streicher, MD

Published May 9, 2014, Everyday Health

Between the “expert” at Whole Foods, your hairdresser, and your most savvy friend, it’s hard to know who or what to believe when it comes to hormone replacement therapy (HRT). Even your gynecologist and internist may give conflicting recommendations! My new book, Love Sex Again, is your go-to guide for comprehensive, medically accurate information on hormone therapy risks and benefits. Here’s the scoop on some common hormone replacement therapy myths.

Myth No. 1:  Local vaginal estrogen carries the same risks as oral estrogen.

The facts: FDA class labeling requires all products with the same ingredient to have the same warning, even if the problem indicated by the warning has never been demonstrated in that product. That’s why risks associated with oral estrogens are listed on vaginal estrogen rings, tablets and creams even though not one single complication, warning or risk listed on the package insert (dementia, blood clots, breast cancer, oh my!) has ever been shown to result from using a local vaginal estrogen product. There is a movement among scientists to get these dire warnings off the label, since there is no evidence of truth, and many women who would benefit are too frightened to use vaginal estrogen products.

Myth No. 2: Bioidentical hormones are ‘natural.’

The facts: The only way to really get a natural bioidentical hormone is to drink the horse urineor eat the soy plant. All plant-derived hormone preparations, whether they come from a compounding pharmacy or a commercial pharmacy, require a chemical process to synthesize the final product, which can then be put into a cream, a spray, a patch, or a pill.

Promoters of compounded, plant-derived hormones use the terms “natural” and “bioidentical ” because they are appealing to consumers and imply an advantage over manufactured pharmaceutical products. FDA approved plant-derived products from your corner drugstore are just as “natural” as the products you get from a compounding pharmacy.

Myth No. 3: Saliva levels are a useful way to determine hormone therapy dosage.

The facts: No one argues that estrogen and progesterone levels are detectable in saliva, and it would be great if a drop of spit could actually unravel the mysteries of menopause. Unfortunately, salivary hormone levels, which are used to create the illusion of individualized therapy, are not biologically meaningful; do not correlate with blood levels; vary depending on diet, time of day, and other variables; and have not been proven useful in any scientific studies in determining the appropriate dosage for hormone replacement.

Likewise, blood tests, while more accurate, are not routinely used to determine the appropriate dosage of hormone therapy since there is a wide range of “normal” blood levels. What matters is not a target number, but how someone feels.

Myth No. 4: Estrogen therapy is a leading cause of breast cancer.

The facts: This is the one that will have a lot of you shaking your heads and thinking, “Is she kidding?” But the facts speak for themselves. Over 80 percent of women who have breast cancer have never taken hormones. In addition, the risk of developing breast cancer from hormone therapy is lower than the risk associated with daily alcohol use or obesity. According to the 2002 WHI study (the one that made women across the nation flush their estrogen down the toilet) only the women who took estrogen and progestin together had a slight increase in breast cancer.

The news flash that didn’t make it to the news is that in the estrogen only group there was an 18 percent decrease in breast cancer. It is now clear that the modest increase in breast cancer in women who take hormone therapy is due to the progestin, not the estrogen.

Myth No. 5: Orgasms require estrogen.

Rejoice! Even if your estrogen tank is on empty most women can still experience the big O. Appropriate local or systemic estrogen therapy goes a long way to make intercourse more comfortable if pain or dryness is an issue, but it does not appear that addition of hormone therapy is necessary for most women to have an orgasm. Having said that, there is data that suggests that supplemental estrogen alone or with testosterone in some post-menopausal woman will facilitate orgasm by increasing blood flow and sensitivity to the clitoris.