Spring means many things including rebirth, new beginnings, and romance. A recent patient, Shelley, came to see me for complaints of pain with intercourse that had kept her from sex for over 6 months. She and her husband were planning an anniversary trip, and she was sad they would not be able to be as intimate as she wanted. She was afraid of pain, he was afraid to hurt her, and they were having a hard time discussing the subject. They were both afraid a component of their marriage was over, and both were attempting to grieve a wonderful sex life.
She thought pain and dryness was a part of aging she would have to accept, but recently had heard otherwise from a friend who had found answers at our Spectrum Health Medical Group Midlife and Menopause Health Offices. Using knowledge from education through NAMS and ISSWSH, my team of providers can understand concerns, assess signs and symptoms, provide a thorough assessment, and offer science-based options to successfully treat such concerns.
Shelley told me that she and her husband had always enjoyed good sex; they made time for each other, had a good relationship for the most part, and still enjoyed being in each other's company. They were active, exercised, and had no major health concerns. Their kids had all moved out and were doing well in their chosen career paths and a grandchild was on the way. She and her husband still both worked, had friends, and were fortunate to be healthy and without major stressors of money, health, job security, or family issues. She had looked forward to this part of her life with anticipation of time alone with her husband and sex without worrying about kids interrupting. Pain with sex was never part of her picture.
Discovering the Problem
Shelley was in early menopause, about 10 months from her last menstrual period. She chose not to take hormone replacement therapy because she had minimal symptoms of menopause and found that if she limited wine and sugar and drank adequate water, the hot flashes were kept to a minimum, and her sleep and moods were rarely dysfunctional. She had regular bowel movements which were generally formed, and ate a healthy diet. When I asked her about other symptoms, she complained of feeling vaginal dryness and pain upon entry, difficulty having an orgasm in that it took a lot more work, and itching on the outside which could be distracting. She also complained about a vaginal discharge with some odor.
Her family practice doctor had treated her over the phone for a yeast infection several times with no resolution of her symptoms. Shelley had no allergies to medications, took a low-dose statin for familial hypercholesterolemia, and thyroid medication. She also took her Vitamin D and had adequate calcium in her diet. She had no major medical problems and was up to date on her screening exams. Shelly just wanted to have good sex again!
On physical exam, her vitals were adequate, her BMI 30, and was otherwise unremarkable except for her pelvic exam. On careful visual exam of her vulva and perineum, I saw right away what was causing at least some of her pain. There was loss of architecture of the labia minor, with reabsorption of the lower third of the labia minora into the labia majora. There was agglutination under the clitoris and 'cut lines' of active agglutination leading down from the mons along the lateral edge of the labia minora. The perineum had several 'cut lines' of agglutination and a whitish color change. There were no obvious areas of skin breakdown or redness, but the human remnants were pale and prominent and the urethra appeared 'shrink-wrapped' -both signs of vaginal atrophy. Her vaginal pH was 6.0, and speculum exam showed me pale flat vaginal walls with a yellowish discharge in the posterior fornix. My bimanual exam was negative for pelvic mass or prolapse, and her uterus was normal parous size and non-tender. Her pelvic floor muscles were tender-both right and left levators and pubococcygeus. A wet mount showed mostly clue cells without white cells or yeast, and a positive whiff test. I performed a biopsy of the perineum with 3 mm punch, and closed it with one stitch of 5-0 monocryl. I ended the exam by showing her all my findings and the location of the biopsy with a mirror.
I was able to tell her all of the conditions I had found were fixable and I was very confident she would once again have sex without pain. We would go over each and discuss treatment options, and I would see her in follow-up to confirm she felt she was on the right track.
The Diagnosis
First of all, vaginal dryness from low estrogen can occur even before the last menstrual period and, like bone loss, is a symptom of menopause which does not resolve with time but instead becomes worse. In a joint effort, NAMS and ISSWSH have named the condition "GSM" or Genitourinary Syndrome of Menopause to replace the term VVA, or Vulvovaginal Atrophy.
With the loss of estrogen, vaginal and genitourinary tissues lose elasticity, turgor, and capillary blood supply. With low estrogen, the pH rises over time, and the vaginal biome can be affected. The result is dryness, fewer secretions, and less of a sexual response, and more allowance for the overgrowth of anaerobes. With loss of turgor of the anterior vaginal wall, the urethra tends to angle down and be more exposed to urinary track pathogens leading to more bladder infections.
Perhaps unrelated to menopause and but perhaps more symptomatic in a low estrogen state, lichen sclerosis is a very common condition of the vulva, and is associated not only with symptoms of pain with intercourse and itching, but also with an increased risk of squamous cell carcinoma of the vulva. I admit to not always performing biopsy unless I am concerned about carcinoma, but treatment can affect the pathology and it can be helpful to have an initial biopsy proving diagnosis. Lichen sclerosis is a life-long condition and patients should be counseled accordingly. Lastly, at least in my practice, I see bacterial vaginosis commonly associated with menopause and even more so in a women with frequent loose stool. It only makes sense that in a hypo-estrogen state, and with contamination of bacteria, infection would be more common.
High tone pelvic floor dysfunction can be very common in women who have had pain with intercourse, either as an initial cause of pain or as a response to pain. The current DSM-IV has gotten rid of the term vaginismus, but the concept is teleological, and to be resolved must be acknowledged and treated by a professional.
Once Shelley was dressed, I went back into her room and drew her a color-coded picture of her bottom (as well in my Epic chart) and listed my findings and explained the conditions and causes. For treatment, Shelley chose vaginal estrogen in cream form, 0.5 gm applied by rubbing into the skin just outside and inside the hymenal ring every night for 5 nights and then twice a week, a short course of vaginal wall antibiotic cream to treat the bacterial vaginosis, and clobetasol ointment applied to the affected areas of her vulva in a very thin coat with a plan to wean down to a low weekly maintenance dose.
I recommended referral to the pelvic floor physical therapist for her pelvic floor high tone and advised her not to attempt vaginal intercourse until medical and physical therapy was providing objective improvement. We laughed that coconut oil is being touted as good for skin as well as cooking, and that it can be a safe lubricant for sex as well. I recommended she take the diagram back home and use it as a tool for discussion with her husband to show there was a plan forward.
All Systems Go
I saw Shelley back in the office in 4 weeks, and several weeks before her planned vacation. Her infection was resolved, the estrogen had taken its effect, and the biopsy-proven lichen sclerosis was vastly improved. She and her husband had talked about sex in a more open way than they had in years and were excited to reconnect in more complete way than ever before. They had had "outercourse" several times, and she was happy to report she had achieved orgasm for the first time in 6 months!
She had been to the pelvic floor physical therapist twice, and had learned how her core was tied into her pelvic muscles, and after learning core and pelvis strengthening and relaxation techniques as well as going through a short course of using progressive vaginal dilators, she had confidence that she was ready to attempt vaginal intercourse and was again looking forward to her anniversary trip
Libido can be affected by many factors including low estrogen and testosterone, depression, life dissatisfaction, relationship issues such as not feeling valued or safe, fatigue, and pain. Over 60% of women report some dissatisfaction with their sex life, and it can significantly affect their quality of life.
For even those who do not have distress related to their symptoms, and therefore do not require or request treatment, in our practice we make it a routine practice to ask about satisfaction with the level of sexual activity and interest and to provide education and options, including referral to other professionals for conditions we do not feel comfortable treating. Even for those who have given up hope, spring can once again come for low sexual desire and sexual pain.
"Lady Doc" is Diana L. Bitner, MD, NCMP, assistant professor at Michigan State University's College of Human Medicine and director of Women's Health Network at Spectrum Health in Grand Rapids, Mich. After 20 years in obstetrics and gynecology, Bitner wrote "I Want to Age Like That! Healthy Aging through Midlife and Menopause" (2014), an educational tool for patients and providers.
For more clinical guidance from Diana L. Bitner, MD, NCMP, see: