Vaginal dryness

The walls of the vagina are kept moist continuously, and that moisture depends on oestrogen. When oestrogen falls, the lining becomes thinner, drier and more easily injured: stinging, itching, a chafed feeling and pain during sex appear. This is not an "inevitability of age" and not something to be endured: dryness almost always has an identifiable cause, and most of those causes have a remedy that works. People stay silent about it for years mainly because the subject feels awkward, not because nothing can be done.

How it feels

Dryness rarely stops at dryness. Several signs usually gather at once, and together they show that the problem lies in the state of the lining rather than in an infection.

• Pain or stinging during sex, sometimes only on penetration, sometimes for the whole of the next day. A little bleeding may follow, from tiny splits in the lining.
• A constant sense of dryness, chafing and tightness, which is a nuisance outside sex as well: when walking, in tight clothes, when sitting.
• Itching and stinging at the entrance to the vagina and on the outer lips, with redness.
• Needing to pass urine often, stinging when you do, false urges and repeated urinary infections: the same tissue lines the opening of the urethra too.
• Less discharge than usual, or the opposite — a scanty watery discharge caused by irritation.
• Less desire, which usually follows on: the body has already learnt to link sex with pain.

Not being lubricated at a given moment is not the same as a dry lining: if it happens only occasionally and in a hurry, the problem lies in the situation and not in the state of the tissues.

Oestrogen: the commonest cause

In the great majority of cases dryness comes down to a fall in oestrogen, and these are the times when that happens.

• The perimenopause and the years after the menopause. This is the commonest cause of all. It begins while periods are still there but irregular, and unlike hot flushes it does not pass with time: left alone, it slowly gets worse.
• After childbirth and while breastfeeding. As long as feeding continues oestrogen is low, and dryness can be pronounced. It is temporary and resolves when the cycle returns, but there is no need to put up with pain during those months — moisturisers and lubricants work here too.
• After the ovaries are removed, and also after they have been irradiated or after chemotherapy. Here oestrogen falls not gradually but all at once, and the dryness is usually harder than in a natural menopause.
• During treatment for breast cancer. Medicines that block the action of oestrogen cause dryness in almost everyone who takes them. There is no need to resign yourself to it, but neither should you decide alone: what to use is agreed with the doctor managing the treatment.
• Early ovarian insufficiency is an uncommon cause, but it is considered when dryness and an unsettled cycle appear well before the usual age of the menopause.

Medicines and other causes

If age has nothing to do with it, it is worth going through the rest. Often the cause is in the medicine cabinet.

• Antihistamines dry every lining, not just the nose; vaginal dryness from them is familiar to anyone who takes them in courses for allergy.
• Antidepressants, particularly those from the group that raises serotonin: they cause both dryness and less arousal.
• Some hormonal contraceptives, especially those with a low oestrogen dose, and those containing progestogen only.
• Medicines for high blood pressure and water tablets, treatments for an overactive bladder, some allergy and travel-sickness remedies.
• Soap, gels and douching. This is dealt with separately below: it is the cause created by one's own hands, and also the one that most often gets in the way of treatment.
• Smoking worsens the blood supply to the lining and brings the menopause forward.
• Skin conditions of the area. Lichen sclerosus and lichen planus cause dryness, itching and cracks, but they need an entirely different treatment; so persistent dryness with skin that looks changed is a reason to be examined, not to buy a lubricant.

If the mouth and eyes are dry as well

This is the case where a single extra complaint changes the whole picture. In Sjögren's syndrome the immune system damages the glands that make fluids, and the dryness becomes general: vaginal dryness together with a constantly dry mouth and dry eyes is a reason to tell a doctor about all three at once.

How it looks. In the eyes: grittiness, stinging, discomfort in bright light, worse by the end of the day, and artificial tears helping only briefly. In the mouth: dry food is hard to eat without a drink, you have to drink at night, the tongue sticks, decay appears at the neck of the teeth and thrush keeps coming back at the corners of the mouth. Dry skin and a dry nose, joint pain, marked tiredness and sometimes swelling of the salivary glands near the angle of the jaw often join in. The illness most often begins in women around their forties and fifties and is easily put down to the menopause, because dryness and tiredness fit there as well.

Why it matters to name it: the diagnosis changes what is done. Local products are not enough here; tests are needed — a blood test for particular antibodies and an assessment of tear and saliva production — along with medical follow-up, because this illness has other features besides dryness. Suspecting it yourself is entirely possible, and the combination of three dry sites is in fact where doctors usually start. We have separate pages on dry eyes and on dry mouth, where the same ground is covered in detail.

Moisturisers and lubricants: the difference

These are confused all the time and the wrong one gets bought. The difference is simple: one is used regularly, the other before sex.

Vaginal moisturisers hold water in the lining and are used as an ongoing routine — usually every few days, regardless of sex. Their effect builds up: after two or three weeks the stinging and tightness lessen. This is the mainstay when dryness is constant.

Lubricants act only while they are applied and are used immediately before and during sex. They do not treat underlying dryness.

What is worth knowing when choosing:

• A water-based lubricant is safe with condoms; a silicone one lasts longer and works in water but can spoil some toys. Oil-based products and petroleum jelly destroy latex, so they are not combined with a condom.
• Products with fragrance, with a cooling or warming effect, and with a lot of glycerine often cause stinging themselves.
• Ordinary body creams, lotions, soap and antiseptics are not put inside the vagina: they irritate the lining and bring on thrush.
• Use more lubricant than seems necessary, and top it up as you go.

Local oestrogen, and why pain is not to be endured

When moisturisers are not enough, there is a treatment that acts on the cause: oestrogen as a cream, gel, vaginal tablet or ring. It restores the thickness and elasticity of the lining, the blood supply and the normal acidity, and along the way it reduces frequent urges to pass urine and repeated urinary infections. It does not act at once: improvement is usually noticeable within a few weeks and complete within two or three months, so stopping after a week makes no sense.

A doctor prescribes it, and it is not the same as hormone therapy in tablets or patches: the dose here is very small and works mainly where it is applied. The list of restrictions on local oestrogen is therefore different and generally much shorter; in particular, it suits many women for whom general hormone therapy is not appropriate. The decision is still taken with a doctor, and with particular care after treatment for breast cancer.

One thing deserves saying separately, because it is what holds people back most: pain during sex is not to be endured and you cannot "get used" to it. Pain makes the pelvic floor muscles tighten reflexly, which hurts more still, and a fear appears that in time stands on its own. Breaking that circle is easier the sooner it is started: besides moisturisers and oestrogen, what helps is going slowly, talking it over with a partner, and — if the muscle tension has already set in — work with a pelvic floor physiotherapist.

What must not be missed

Dryness is a benign condition, but there are signs where what is needed is an examination rather than a choice of product.

• Any bleeding after the menopause, even a single scanty episode, and bleeding after sex when it recurs.
• Sores, raw areas or cracks that will not heal on the lining and on the outer lips.
• A persistent white patch, a thickening, a lump or a plaque, especially if the area does not settle over several weeks, itches or changes shape. This is how lichen sclerosus looks, which is treated with a steroid ointment, and it is also how a cancer of the vulva can begin — it responds well early on and therefore needs to be looked at rather than watched from home.
• Folds flattening or fusing, and narrowing of the entrance to the vagina.
• Discharge with a smell, with pus, or green or grey in colour — that already points to infection, and a swab is needed.
• Pain low in the abdomen with a fever.

Examining this area takes minutes and usually answers the main question straight away. There is no reason to feel embarrassed: a good share of the dangerous changes of the vulva are found exactly this way — by a doctor's eyes, in women who came about dryness and itching.

Online consultation

Starting with an online appointment suits dryness well: there is no need to wait until it becomes unbearable. From your account a doctor will work out what is in front of them — falling oestrogen, a reaction to a medicine, the consequence of soap and douching, or a skin condition that has to be examined. They will go through your list of medicines with you: sometimes changing one is enough. They will explain how a moisturiser differs from a lubricant and how to use each so that it does some good, and say whether local oestrogen is worth discussing in your case. If the mouth and eyes are dry too, they will help test that possibility and name the right blood tests. And they will say separately in which situations an in-person examination is needed within days rather than in a month's time.

This material is for information only and does not replace medical advice.