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.

Vaginal Estrogen for Women with Breast Cancer?

 by Lauren Streicher, MD

For the woman who is newly contending with a diagnosis of breast cancer and dealing with the overwhelming stress of surgery, chemotherapy and radiation, sex is usually the last thing on her mind. The emphasis is, and should be, on treating the cancer. But after the physical scars have healed and hair has grown back, the consequences on a woman’s sexuality are often minimized. Sadly, many cancer survivors feel reluctant to complain about something as “trivial” as the loss of their sex life. It’s not unusual for a breast cancer survivor to attempt intercourse, only to find what was once satisfying and enjoyable is intolerable and upsetting, If she is brave enough to bring it up to her doctor, it’s typical to not get a lot of advice beyond “buy a lubricant” When that doesn’t work most women give up, assuming that vaginal estrogen, the most successful way to reverse vaginal dryness and intercourse, are just not an option.

Even if a doctor does give the go ahead, many women take one look at the package insert that practically has a skull and cross bones on it and decide it just isn’t worth the risk.

I published a study in 2013 in The Journal of Sexual Medicine showing a majority of gynecologists would themselves use vaginal estrogen even if they had breast cancer. It’s not that gynecologists are more willing than the general population to risk their lives in the name of having good sex, it’s that gynecologists know that the Black Box Warning that lists the dangers of using estrogen is not based on data that has anything to do with vaginal estrogen, much less women with breast cancer who use vaginal estrogen.

Today, the American College  of Obstetricians  and Gynecologists (ACOG) released a position statement very clearly stating that the use of estrogen in women with a history of an estrogen dependent breast cancer is safe and appropriate . ACOG  states, " Data do not show an increased risk of cancer recurrence among women currently undergoing treatment for breast cancer or those with a personal history of breast cancer who use vaginal estrogen to relieve urogenital symptoms. "

Since there is   essentially no evidence that using a tiny amount of estrogen directly on vaginal tissues to increase lubrication and elasticity of tissue that has become thin and dry causes an increased risk of breast cancer recurrence, it is time for the  FDA to   remove the scary, inappropriate black box warnings. Clearly the miniscule amount of estrogen absorbed from the vaginal use of estrogen doesn’t even increase blood estrogen levels above the normal menopausal range andis not  risky.  And in fact, what little data there is regarding the use of vaginal estrogen in women with breast cancer is very reassuring. One study which was published in a medical journal (Climacteric 2003; 6:45-52) followed 1,472 breast cancer patients who routinely used vaginal estrogen and were found to have a LOWER recurrence rate than women who did not use vaginal estrogen.

Most  breast surgeons and oncologists are  now comfortable allowing women with breast cancer to use vaginal estrogen. Ultimately, you need to do what you are comfortable with, but if you do decide to use vaginal estrogen, it should ease your anxiety a lot knowing not only most gynecologists, but alsoACOG is now firmly on board. 


Barriers to Entry: The Economics of Midlife Sex

By Lauren Streicher, MD


I was sitting across from Jill, a long-term patient of mine who was in for her annual exam. The year before we had spent a lot of time talking about strategies to deal with painful intercourse that had left her pretty much in avoidance mode. She had left my office with a prescription for alocal vaginal estrogen product along with a number of over the counter recommendations.

“So, how are things going sexually” She gave a dismissive wave of her hand, and said, “We gave up on that. ” What about all the things we discussed last year?” “Frankly”, she said,” Between my husband’s issues and my issues we added it up and realized we couldn’t afford it. It’s OK. “

Couldn’t afford sex? Sex is one of the few pleasures in life that’s free! That’s like saying you couldn’t afford to go for a walk, or give your partner a nice massage. And for some people, that’s true. But shame on me, I had never really considered the cost of the products that for some people, don’t just makes intercourse pleasurable, but make it possible. Even if you have insurance that covers part of the cost of the prescription products, many Americans are uninsured or underinsured. Over the counter products are rarely covered.

So I added it up and was shocked at the economics of midlife sex. Here’s what I came up with as the average annual cost for a typical couple that has sex twice a week and requires a little help to keep things going:

Silicone Lubricant  $15.99 (roughly 4 bottles/year) $64

Local Vaginal Estrogen $40-80/month $720

Long Acting Vaginal Moisturizer $19 /month $240

Erectile Dysfunction Medication $35/pill $3,360

Doctor’s visits to get prescriptions $300

Total: $6,202/year

Not everyone requires all these products, but depending on what someone needs, it’s dramatically cheaper to go to the movies one a week than to make love. And that’s not including the cost of a little new lingerie, candles, a vibrator and maybe the occasional bottle of champagne. I wondered how many of my patients had given up their sex lives not just because it was difficult or painful, but also because if there was a choice between buying groceries or buying Viagra, eating trumps pleasure.

The solution? You can get some breaks by checking out the coupons on the pharmaceutical web sites. See if your insurance will cover over the counter products if you have a doctor’s prescription. Ask your doctor for samples and see if a ½ Viagra and vaginal estrogen once a week rather than twice a week will do the trick. Beware the mail order stuff, (it’s almost always fake!) and tell your children that next mother’s day, skip the flowers and send some lube.

Originally pubished Aug 16, 2013 Everyday Health

When Taking the Pill Takes Away Your Sex Life

By Lauren Streicher, MD


For the last 50 years, birth control pills have given women the power to determine when they get pregnant. But for some women, the very pill that allows this freedom can impact libido and vaginal lubrication such that many lose the desire to have sex in the first place.

If you take birth control pills and can’t figure out why your vagina is like the Sahara Desert in spite of being 25 years old and totally in lust with your partner, you are not imagining it. It’s real and it’s likely that your birth control pill may be the problem.

For Most Women, the Pill Is a Good Thing
For the lucky majority of women, hormonal contraception enhances sexual health, and most pill users have more frequent sexual thoughts and fantasies, better orgasms and more interest in having sex. Removing fear of pregnancy, cramps, PMS and heavy bleeding also goes a long way to a better sex life.

For Some Women, the Pill Is a Problem
Thanks to the groundbreaking work of Dr. Andrew Goldstein, who sees hundreds of women a year at his Center for Vulvo-Vaginal Disorders, it is now appreciated that a small but significant percentage of women on hormonal contraception not only have reduced libido but also experience painful intercourse. Dr. Goldstein observed that many young women taking low-dose birth control pills experienced symptoms normally seen only in menopausal women with low levels of estrogen, the hormone that increases sex drive and contributes to normal vaginal lubrication. Given that birth control pills contain estrogen, one would think that the pill would be a major sexual booster, but Dr. Goldstein discovered that the explanation was in the other part of the hormone cocktail that’s responsible for sexual health: testosterone.

Less Testosterone, Less Libido
Birth control pills lower the amount of testosterone produced by the ovaries and increase a protein secreted by the liver known as sex-hormone-binding globulin (SHBG). SHBG binds to testosterone and makes the molecule inactive. The higher the SHBG level, the lower the functional testosterone level. Lastly, the synthetic progesterone component in some birth control pills actually poisons the testosterone receptor if given in high doses. Since both estrogen and testosterone receptors in the vagina contribute to lubrication, it is understandable that low testosterone not only makes things drier, but also more painful, a condition known as hormonally mediated vestibulodynia. (The vestibule is the area at the opening of the vagina, anddynia is the Latin root for pain).

If that wasn’t bad enough, low testosterone can also lead to fatigue, lethargy and moodiness, all symptoms that make you more likely to want to take a nap than make love.

Anatomical Changes
If you needed any more convincing that the changes that occur on the pill are not just “in your head,” a study that was published in the Journal of Sexual Medicine in 2012 measured the thickness of the labia minora, the size of the clitoris and the size of the entrance of the vagina in women on the pill. It found that after only three months of use, pill users had thinner labia, smaller clitorises and a decreased entrance of the vagina that correlated with increased pain during intercourse. In addition, these same researchers showed decreased orgasm in the women on the pill.

The Terrible Testosterone Trifecta
While most women do not have this problem, Dr. Goldstein discovered that about 5% of women have a genetic variant that results in a defective or inefficient testosterone receptor. These women require much more testosterone to keep the vulvar and vaginal tissue healthy and for their glands to function normally. The effects are not obvious until testosterone levels become lower than normal, but that happens to every woman who takes the pill.

So, in women with this genetic variant, the problem is threefold:

1. The pill causes the ovaries to produce less total testosterone and less is in a usable form.

2. The synthetic progesterone found in newer birth control pills poisons the testosterone receptor at high doses.

3. The testosterone receptor doesn’t work well, making it extra dependent on high amounts of testosterone being present.

The Solution
So, if you are on the pill and find you would rather play Sudoku than play with your partner, what options do you have? Ideally, women who have this condition should not take the pill and instead use an alternative method of contraception, such as an IUD. A local vaginal estrogen and testosterone cream (by prescription from a compounding pharmacy) can also facilitate healing. Be patient, it usually takes months.

If another method of contraception is not an option, know that some pills may be better than others. Very-low-estrogen pills that contain drospirenone, desogestrol or norgestimate seem to have the greatest negative impact on libido and vaginal dryness, so if you’re taking one of these, talk to your doctor about whether it’s contributing to any symptoms you might have. Use a silicone lubricant, and ask your doctor for a prescription for hormonal creams to apply to the opening of the vagina. And know that you are not crazy.