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Vaginal issues

Menopause Oasis
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Just how does the vagina (vaginal canal) usually function?  Concerned with vaginal dryness?  Vaginal discharge ~ is it normal or abnormal?  These are the issues we'll discuss on this page!

The vagina (vaginal canal) and its function
 
This is the female internal sex organ that begins on the outside at the vaginal opening and extends three to five inches inside. It ends at the cervix (or neck) of the uterus (womb).
 
It is made up of three layers of tissue...
 
The first layer is the mucosa.  This is the layer on forms the surface that can be touched. It is made up of of mucous membranes similar to the lining of the mouth.  However, unlike the smooth surface of the mouth lining, the vaginal mucosa has many folds or wrinkles. This texturing provides the man with the friction he needs to climax during intercourse.
 
The next layer is muscle. It is concentrated mostly around the third of the vagina nearest the outter opening. This muscle layer contracts during arousal, firmly gripping the penis during intercourse.
 
The third layer is made up of fibrous tissue that connects to other internal anatomical structures and helps provide structural support.

The Shape...
 
The vagina is shaped rather like a flattened tube, the sides of which are collapsed on each other. It is not a constantly open tube (or hole) as so many men and women think. It is a "potential space". 
It is because of its muscular tissue that the vagina has the ability to expand and contract, and thus allow a baby to pass through during childbirth, or adjust to fit snugly around a tampon, a finger or any size penis.
 
During sexual arousal two things happen to lengthen the vagina; first the swelling of the labia majora moves the entrance outward, and next the back of the vagina extends past the cervix into the body. The lower third of the vagina closes down, while the upper two thirds opens up.

Nerve endings...

There is not a large supply of nerve endings in the internal walls of the vagina, thus it is not very sensitive to touch. The outer one-third of the vagina, near the opening, contains nearly 90 percent of the vaginal nerve endings. It is therefore is much more sensitive to touch than the inner two-thirds of the vaginal canal which is usually incapable of discerning touch.
Vaginal Fluid...

The walls of the vagina continually produce secretions which moisten and clean the vagina. During sexual excitement, small droplets of fluid appear along the vaginal walls eventually covering the sides of the vagina completely. There are no secretory glands in the vaginal. Rather it is loaded with blood vessels that, when engorged with blood as a result of sexual arousal, press against the vaginal tissue, forcing natural tissue fluids through the walls of the vagina. Because thislubricant is subject to gravity, it may not readily reach the entrance of the vagina if the woman is laying down. The quantity and thickness of the lubricating fluid varies from woman to woman, and changes considerably during a woman's cycle.
 
The fluid serves as a lubricant for intercourse if that is what is to follow sexual arrousal. Without this natural lubricant (or an artificial one) womenn would find penetration painful.  On occasions when the process of vaginal expansion and/or lubrication does not happen as 'designed' the results can be both physical and emotional pain.
 
It was once believed that the Bartholin's Glands (which are located on each side of the labia minora (inner lips of the vaginal opening) supplied the lubrication for women during sexual arrousal. It has since been shown that they secrete only small amounts (a drop or two) of fluid when a woman is sexually aroused.

As we reach peri-menopause or post-menopause we often begin to suffer from vaginal dryness or itching. Some of us notice that our clitoris seems to shrink.  Many of us develop some bladder leakage or mild incontinence and we also suffer from constant recurring urinary tract infections. Often sexual intercourse becomes painful.

 

These symptoms can all be caused by the loss of estrogen and the ensuing atrophy of the vaginal, and surrounding, tissues.

 

Yes, the Kegel exercises can help strengthen the muscles in that portion of our body, but it cannot return the suppleness or moisture to those mucus membranes that lie within.

 

The most unfortunate thing is that these issues will NOT go away on their own and over time (without proper treatment) will only worsen.

Vaginal atrophy (atrophic vaginitis) is thinning and inflammation of the vaginal walls due to a decline in estrogen. Vaginal atrophy occurs most often after menopause, but it can also develop during breast-feeding or at any other time your body's estrogen production declines.
 
A drop in estrogen levels and vaginal atrophy may occur:
    * After menopause
    * During the years leading up to menopause (perimenopause)
    * During breast-feeding
    * After surgical removal of both ovaries (surgical menopause)
    * After pelvic radiation therapy for cancer
    * After chemotherapy for cancer
    * As a side effect of breast cancer hormonal treatment
 
There are medications containing antiestrogen properties that can cause this condition:
    Tamoxifen (Nolvadex)
    Danazol (Danocrine)
    Medroxyprogesterone (Provera)
    Leuprolide (Lupron)
    Nafarelin (Synarel)
 
Symptoms associated with vaginal atrophy are:
    * Vaginal dryness / itching
    * Vaginal burning
    * Burning with urination
    * Urgency with urination
    * More urinary tract infections
    * Urinary incontinence / frequency
    * Light bleeding after intercourse
    * Discomfort with intercourse
    * Shortening and tightening of the vaginal canal
 
For many women, vaginal atrophy makes intercourse painful — and if intercourse hurts, your interest in sex will naturally wane. In addition, healthy genital function is closely intertwined with healthy urinary system function.
 
Make an appointment to see your doctor if you experience painful intercourse that's not resolved by using a vaginal moisturizer (see the Vaginal Dryness section on this page for help with that), or if you have vaginal symptoms, such as unusual bleeding, discharge, burning or soreness.
 
Simple, effective treatments for vaginal atrophy are available. Reduced estrogen levels do result in changes to your body, but it doesn't mean you have to live with the discomfort associated with vaginal atrophy. There are several forms of vaginal estrogen that can be prescribed to help you.

What can be done to help alleviate Vaginal Dryness?

There are many products available that help relieve vaginal dryness. 
 
If you are suffering from vaginal atrophy(shrinking) and bladder leakage chances are you may need a prescribed vaginal estrogen.  These can often be safely used by women who have been told to avoid estrogen as they are only minimally absorbed into the system.  They provide considerable, and long lasting, relief from vaginal dryness, itching, tearing and also bladder leakage. This type of product provides a localized effect that rebuilds the lining of the vagina and the urethra and promotes collagen production.  Talk with your family doctor or GYN about this. 
 
Some women have allergic reactions (actually causing more dryness and/or other issues) to ingredients in some of these products.  You may want to check the product labels to be certain that the one you choose does not contain any harsh chemical ingredients, petrochemicals, endocrine disruptors, or irritants to which you may have a sensitivity - such as alcohol, parabens, or propylene glycol.
 
Some of the estrogen products that have been developed for this purpose are:
  Estrace Cream
  Estring (cervical ring) 
  Premarin Cream
  Ogen Cream
  Vagifem  (vaginal tablet)
 
If your symptoms are less severe or you do not have insurance or your insurance will not pay for prescribed vaginal estrogen; there are OTC products that may be of help to you.
 
I have lumped them into 3 categories and each brand name is linked to a short piece of information about the product (where I could find any). Some of these are sales sites, sorry!
 
Designed for vaginal insertion and provide some longer lasting aid:
Replens
Gyne-Moistrin
 
Designed for application to the vaginal opening and penis:
KY Jelly (check out their entire offering at this site!)
Senilube  (previously named Senselle)
 
Then there are some products that are designed to provide 'additional' fun:
Lube-a-Licious
Astroglide Warming
K-Y Warming Liquid

Added in August 2014......
A new product is being offered via a doctor's prescription.  It is Osphena. It is advertised as:  "The only non-estrogen, oral treatment for moderate to severe painful intercourse due to menopause that actually improves certain physical changes of the vagina (including superficial and parabasal cells, and vaginal pH)."  To read more about it check out this link.

What can cause dryness?

Physical problems:
It can be the result of a hormone deficiency, a vaginal infection or a cyst in the vagina. Some forms of birth control (one that is high in progesterone) can experience lessened vaginal lubrication.
 
Relationship Problems:
Emotional problems can be the reason behind too little vaginal lubrication. Emotional upset may block natural physical responses. Sometimes this can be dealt with by the couple, sometimes counseling is needed to remedy this kind of problem.

Vaginal lubrication often decreases as women age. During perimenopause and postmenopause, the body produces less estrogen. This, unless compensated for with some form of estrogen replacement therapy, causes the vaginal walls to thin out significantly. The vagina also tends to become slightly shorter and narrower, and loses its ability to expand as easily during sexual excitation. It takes longer to produce even a reduced amount of lubrication. This is known as vaginal atrophy.
 
A woman not using estrogen replacement may use artificial lubricants although their end results are not as long lasting as estrogen therapy. Sometimes engaging in longer periods of foreplay may help post-menopausal women avoid pain with intercourse.

After childbirth a woman's vagina may lose some of its muscle tone, become looser and/or and feel larger. For some women this means that they may not experiennce the physical pleasure they once did from their partner's penis making contact with the vaginal walls. The partner may also notice that he is not held as tightly by the vagina. There are exercises that can help with this issue.  These exercises, called Kegel exercises (after the physician who developed them), consist of contracting the muscles in the pelvic floor that are used to stop the flow of urine. The contraction is held for 3-5 seconds, repeated ten times in a series, and the series is usually repeated several times a day. These voluntary contractions can also be done during intercourse, and some women and men find it sexually enhancing.

In a May 2007 'position statement' issued by the North American Menopause Socity we read, "Although hot flashes typically accompany the loss of ovarian estrogen production at menopause, they usually abate over time regardless of whether estrogen therapy is used."  This statement continues to say "In contrast, vaginal symptoms (eg, vaginal dryness, vulvovaginal irritations and itching, and painful intercourse) are usually progressive and unlikely to resolve spontaneously. Left untreated, vaginal atrophy can result in years of discomfort, with a significant impact on quality of life." You can find, and read that entire statement here.

A normal vaginal discharge consists of about a teaspoon (4 ML) a day that can be white or transparent; thick or thin; and odorless or with a slight, pleasant odor. It is formed by the normal bacteria and fluids that the vaginal cells secrete. The discharge can be more noticeable at different times of the month depending on ovulation, menstrual flow, sexual activity and birth control.
 
During a sexual excitement or emotional stress, the flow increases in amount. A healthy flow is a clear or a white, cloudy color that may become yellow when coming into contact with air.
 
However, a sudden change in volume (especially if other symptoms are present) should be checked by your doctor.

Various Types of Discharge
 
White: Thick, white discharge is common at the beginning and end of your cycle. Normal white discharge is not accompanied by itching. If itching is present, thick white discharge can indicate a yeast infection.
Clear and stretchy: This is "fertile" mucous and means you are ovulating.
Clear and watery: This occurs at different times of your cycle and can be particularly heavy after exercising.
Yellow or Green: May indicate an infection, especially if thick or clumpy like cottage cheese or has a foul odor.
Brown: May happen right after periods, and is just "cleaning out" your vagina. Old blood looks brown. This may also occur when you are ovulating/mid-cycle. Sometimes early in pregnancy you may have spotting or a brownish discharge at the time your period would normally come. If you have spotting at the time of your normal period rather than your usual amount of flow, and you have had sex without using birth control, you should check a pregnancy test.

Diseases that can cause vaginal discharge:
 
Name of infection Is caused by
having sex with
an infected person
What does discharge
look like?
How is the
infection treated?
Yeast Infection No Thick, white, like
cottage cheese
Vaginal creams or pills
Trichomoniasis
("Trick")
Yes Green, yellow, or gray
in color; frothy
Pills ordered by
your doctor
Bacterial vaginosis
(Gardnerella or BV)
Probably not White discharge that
smells fishy
Pills or vaginal cream
ordered by
your doctor
Gonorrhea (Clap) Yes Cloudy or yellow, but
often no symptoms
Pills or shots ordered
by your doctor
Chlamydia
(Kla-mid-ee-ah)
Yes Often no symptoms Pills ordered by
your doctor

Vaginitis is an inflamation of the vaginal canal. It can manifest itself in many ways, from an annoying itch to full blown infection. It is the reason for around 10% of all female visits to their doctors each year.
There are three main causes of vaginitis: hormonal imbalance, irritation and infection.  In many instances of vaginitis in menopausal women it is hormonal (see our section on vaginal dryness).
But there are many other causes too, so do not think that you are "sure" what is causing yours!  It could be an allergy to some product you are using or an infection ~ only your doctor can be sure.
 
There is a very good article at Vitacost.com that delves into the various causes, and possible 'natural' remedies for each that you might find helpful.
 
If you would like to do some more in depth research on this topic check out the MedicineNet.com information.