Patricia Yarberry Allen, M.D. is a Gynecologist, Director of the New York Menopause Center, Clinical Assistant Professor of Obstetrics and Gynecology at Weill Cornell Medical College, and Assistant Attending Obstetrician and Gynecologist at New York-Presbyterian Hospital. She is a board certified fellow of the American College of Obstetrics and Gynecology. Dr. Allen is also a member of the Faculty Advisory Board and the Women’s Health Director of The Weill Cornell Community Clinic (WCCC). Dr. Allen was the recipient of the 2014 American Medical Women’s Association Presidential Award.

Dear Dr. Pat,

I’m a 55-year-old woman who recently went through menopause. I’m healthy and take no medicines or supplements. My mammogram, bone density, and a pap smear a year ago were all normal. My only real problems now seem to be diminished interest in sex, vaginal dryness, and a vaginal discharge with a very unpleasant odor when my husband and I do have sex. Intercourse is painful and I have a constant awareness of that part of my body.

My gyn diagnosed “a pH problem” and prescribed vaginal suppositories to help with the pH, and vaginal hormone therapy. Between these two vaginal treatments I have stuff running out of me all the time and do not feel sexy at all. And some of this stuff actually burns. I am considering oral hormone therapy just to get away from this constant vaginal stickiness. I have always loved oral sex and fear that my husband will never again be tempted to do that for me.
 
Suggestions?

Jennifer

Dear Jennifer,

It should not be a surprise that the body’s tissues change with time. Genital tissue requires the same kind of maintenance that most women devote to the more visible parts of their bodies: skin care, hair cut and color, exercise and weight management, and good dental care.

And no body part should be talking to you. Genital awareness itself is not normal.

The pH that your gynecologist is treating is a symptom, not a diagnosis. In order to effectively treat problems, it is helpful for the medical practitioner to have at least a working diagnosis.

Genital atrophy occurs in almost all post-menopausal patients. With the loss of estrogen the layers of the genital tissue become thin, dry and fragile. Sexual activity, even with lubrication, often causes small abrasions that may become infected over time. This produces sensitive genital tissue, often with awareness, burning, or itching, frequently with a vaginal discharge that has an odor. At this point the genital atrophy, due primarily to estrogen loss, has been converted into some form of desquamative inflammatory vulvo-vaginitis.

These medical names are easy to understand when you think about it. The tissue was thin, then with friction from sexual activity and small tears in the mucosa, the vulvar and vaginal mucosal tissue becomes inflamed and the layers of the mucosa actually become thinner from loss (that is the desquamation part).

Before a final diagnosis can be made, it is important to exclude all sexually transmitted genital diseases, common infections such as trichomonas, and as always, malignancy. This is done by doing a careful physical exam, a microscopic evaluation of the vaginal discharge, cultures of the vaginal fluid, and when the infection is cleared, a pap smear. Blood tests for calcium, vitamin D 25 OH, vitamin D 1,25 di-hydroxy, and parathyroid hormone levels need to be drawn. If you have had kidney stones, a 24-hour urine test for calcium excretion will need to be done within the first three months of treatment, since vitamin D may raise the level of both blood calcium and excretion of calcium in the urine. Most of us have normal calcium and vitamin D metabolism and are very unlikely to have this problem.

Most of the patients who present with the history that you have given will have some form of DIV (desquamative vulvovaginitis). So, there is now a diagnosis and a treatment program can be created to return the genital tissue to health.

Local treatments nearly always fail and, as you’ve discovered, are often so unpleasant that the patient stops the treatment soon after it is prescribed. The pH is higher than it should be, so your gynecologist is giving you a vaginal acid capsule or gel to lower the pH. This will not solve the problem, as you’ve noticed.

In the last five years there has been a growing interest in the role of vitamin D in the regeneration of the many layers of the genital epithelium, along with many other cellular processes that involve the normal proliferation of cells. Most women have low levels of vitamin D, since this vitamin comes primarily from sunlight (even though there is a small amount of Vitamin D found in a diet high in oily fish). We get no vitamin D from sunlight in the northern latitudes after September of each year, and we wear hats and sunblock the rest of the year. This blocks absorption of the ultraviolet waves that have to penetrate the skin in order to convert a compound in the skin to previtamin D3, which is then converted to Vitamin D3. And as we age, our skin’s ability to perform this conversion process is limited as well. (A lengthy explanation, but you get the picture—we need more vitamin D.)

The first step of this rehabilitation program involves daily vitamin D replacement, generally in the range of 5,000 IU of vitamin D3 every day. This is best absorbed with some food low in fiber and higher in fat. (Yogurt or cheese are good choices.) In order to reach a therapeutic range, a woman’s vitamin D level needs to be between 50 and 60, although some patients may require very slightly higher doses that must be carefully monitored.

It takes about 90 days for the genital mucosa to regenerate with this first step. Genital estrogen is then added, if there is no contraindication to its use. Most patients prefer the tablet form of estradiol, Vagifem, since it is not messy. Vagifem is inserted into the vagina every other night for the first two weeks, then twice a week. There are two strengths available, 10mcg and 25 mcg.  Most patients need the 25 mcg dose for the first six months of use.

Once vaginal estrogen replacement has been used for one month, patients generally take vitamin D 2,000 IU a day along with the Vagifem tablet inserted twice a week. Your doctor should monitor your vitamin D and calcium levels at each semi-annual visit. Vitamin D blood levels of 50 are likely to be necessary long term if you plan to continue your sexual life.

There are, unfortunately, some women who have more difficult issues. Drugs that worsen genital mucosal health, like the bisphosphonates that are used for osteoporosis treatment (such as Actonel, Fosamax and Boniva, along with the IV forms of bisphosphoates), proton pump inhibitor drugs that are used for gastro-esophageal reflux disease (such as Nexium and Prevacid), and anti-estrogen therapies for breast cancer—all medications that may be necessary to treat serious medical problems—can make this a very difficult diagnostic and therapeutic problem.

But based on your history, Jennifer, you are likely to respond to this treatment program. The recovery process is about four months. Patients want a quick cream or pill and a return to their normal lives, but this desquamative inflammatory process didn’t occur overnight, and it won’t be cured with a potion to change the pH. As in all things medical, it is absolutely necessary to take a good history, do a careful physical exam, and perform the appropriate laboratory tests. Then the doctor, in consultation with the patient, can decide on the initial treatment program, to be followed by a maintenance program that is right for each patient.

Do remember that this is an answer to your question that you can use to discuss with your gynecologist.

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  • Deborah June 5, 2016 at 7:58 pm

    Thank you so much for the no frills response to very real concerns. I, too, am wondering about this odor that is off-putting to me! Can’t help but be concerned with what my husband thinks about it. It is especially present after intercourse. I don’t want to stop being active with him, but I, like one of the other writers, tend to avoid oral because I feel alarmed by the smell.

    I will approach my OB-G about this. We have dealt with other issues of my lady parts, but an active sex life does not seem to be one of the items on our agenda. I am happy to know that women- even during and after menopause – can still experience healthy sex lives. Like many here, I am one who still enjoys my husband’s attention.
    Thanks again for the explanation.

    Reply
  • Hoosein M. May 23, 2015 at 10:43 am

    Jennifer’s parting concern in a 2010 post is for the loss of her husband’s oral attention. She fails to ask more questions than “Will he/how can he overcome the close proximal environmental side effect issues of discharge and aroma?”

    Dr Pat did not comment in any regard to the more basic concern I have is. “What are the effects on his hormonal health with exposure and likely ingestion of estradiol?”

    Thanks and blessings!

    Hoosein M

    Reply
  • Laura Baker December 21, 2010 at 6:57 pm

    Dr. Pat,
    I forgot to thank you for your valuable information and well researched answers.

    Laura

    Reply
  • dr pat allen April 20, 2010 at 3:31 pm

    I agree that jumping on moving bandwagons is sometimes risky but Myla’s concerns about calcium and vitamin D need to be addressed. Calcium in the recommended doses of 1200 mg a day in divided doses does not cause kidney stones unless the patient has an unusual condition where calcium leaks into the urine (hypercalcuria). This recommendation for calcium used to produce healthy bones has been in place for decades now and there has been no epidemic of kidney stones. After all, each person loses 600mg of calcium in the urine and stool each day! Vitamin D, as discussed in this article, could possibly increase the blood and urine levels of calcium so monitoring twice a year by a health professional is an expected part of this treatment for women who have desquamative vulvovaginitis, vaginal discharge, pain with intercourse and genital atrophy. Myla is right, on rare occoasions, some women need a lima bean amount of estradiol cream on the genital tissue outside the vagina once or twice a week in addition to vagifem. It is a choice, Myla. Does a symptomatic patient want genital burning, itching, vaginal discharge,and pain with intercourse or does she want an opportunity for symptom relief and restoration of normal genital tissue when she is treated based on a plan that begins with a sound diagnosis and continues with careful medical follow up? No medical treatment is without risk, Myla. But quality of life is important to most women.

    Reply
  • Mala April 19, 2010 at 10:26 pm

    I’m disturbed by the advice to get on the vitamin D bandwagon. The current craze. Five years ago it was calcium that was going to set us free. But guess what? Calcium supplements give you kidney stones. Now it’s vitamin D, in very high doses that is being promoted by the pharmaceutical companies who manufacture it. As for Vagifem, it may help with the internal deterioration of the lining of the vaginal canal, but it doesn’t help with the deterioration of the external tissue, on the labia, etc. You’ll be needing Estrace cream for that.

    Reply