A: You have options if you are menopausal or post-menopausal and experiencing vaginal dryness, urinary complaints, or painful sex!
These issues are part of the normal changes that happen in your body during and after menopause. These changes are due to declining estrogen levels, a hormone that supports our vaginal lining’s moisture, and more. However, just because these changes are expected doesn’t mean you have to live with them. There is help! Talk to your clinician about treatments that will work for you. Do not suffer in silence with uncontrollable leaks or give up on activities that bring you pleasure, joy, and connectedness. 
For maintaining sexual health post-menopause:
Consider non-hormonal treatments first
Both estradiol and Premarin used in the vagina are safe in most cases
Avoid compounded vaginal hormone therapies when possible: they are not tested for strength or safety. For some people, these products may be the only affordable option. If this is the case, ask your gynecologist to prescribe just estradiol and at a low dose
There are also treatments for whole-body symptoms of menopause, but that’s a different post (stay tuned, we’re working on it)!
Talk to your clinician about what’s best for you
Let’s talk about a few options.
If you have vaginal dryness or painful sex, your clinician may recommend you try non-hormonal treatments *first* because they often work as well and have fewer side effects.
Non-hormonal treatments include:
Short-acting lubricants used at the time of sexual activity
Long-acting lubricants/lotions used 2-3 times per week regularly
Pelvic physical therapy (think power Kegels and more!)
Non-vaginal intimacy (more time stimulating the clitoris [invest in some vibrators 
], nipples, and other fun zones)
If you do not find relief from non-hormonal treatments for vaginal dryness, painful sex, or you have urinary symptoms, your clinician may prescribe FDA-approved vaginal hormone therapy. Be patient. It can take up to 3 months to feel the full effect. 
Good news: 
Most experts agree that low-dose hormone therapies used in the vagina have a low risk of complications, like heart problems, stroke, or cancer.
There are two types of vaginal estrogens on the market: estradiol products and Premarin.
Fun facts:
Both estradiol, which is an FDA-approved bioidentical hormone (glossary of terms at the end of the post), and Premarin are made in laboratories and use chemical processes to become their final product
Estradiol is derived from yams or soy
Premarin is derived from pregnant horse urine
In this sense, both come from “nature,” and both are changed or “synthesized” in a lab. Both work well!
Vaginal estradiol is available in a cream, tablet, ring, and gel
Something else you might read about is called “compounded” hormone therapy. Compounded vaginal hormone therapies are made from estradiol and sometimes progesterone. They are prepared on demand by a pharmacist. They are generally not recommended, as they are not more effective, and the use of these products has safety concerns.
If you have an estrogen allergy or prefer not to use it, talk to your clinician about a daily vaginal insert such as dehydroepiandrosterone (DHEA). Although it is not the first choice, it may be right for you.
Special note for people being treated for breast cancer *currently*: You may be able to continue your vaginal hormone therapy.
In August 2022, experts added the following guideline: “data support [the] general practice of prescribing vaginal estrogen for management of [vaginal and urinary complaints] in patients with breast cancer treated with *tamoxifen* but NOT those treated with *aromatase inhibitors (AI)*.” UpToDate
Before starting hormone therapy, talk to your clinician about your individual risks. At regular intervals, reassess your symptoms and medications with your clinician.
Thanks to Pepper from Kansas for today’s question. And continue to submit your excellent questions here.
Stay safe. Stay well.
Those Nerdy Girls
Glossary of Terms:
Compounded medication: A medication that is combined, mixed or altered into a formulation meant for one individual patient. This altering is done at a pharmacy, not in a lab. Compounded medications can be helpful and less expensive in certain circumstances but may also come with safety concerns.
Bioidentical hormone: A hormone that is chemically identical to what your body produces (for example, estradiol from the pharmacy is identical to what the human ovaries make). People in labs still need to change (synthesize) the original item (for example, yams) into hormones that your body can use. Bioidentical does not mean risk-free. The risk of any drug/hormone depends on how much, length of use, purity, and personal health factors.
Premarin: A conjugated equine estrogen. In simpler terms, a mixture of estrogens made from pregnant horse urine. Pre(gnant)Mar(es’)U(rin)e. They are not identical to the hormones your body produces, but your body converts them into a form you can use. Counter to popular belief, this type of hormone is the fewest steps away from its original form. In other words, they are the most “natural.” Premarin is more expensive to manufacture than estradiol and therefore costs more for the patient.
Additional Resources:
Johns Hopkins: How sex changes after menopause
A comprehensive and readable guide to all things menopause
Link to original Dear Pandemic Facebook post
References:
Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment
