What’s New in Vaginal Rejuvenation? Newer treatment for vaginal and pelvic concerns in women

By: Holly L. Thacker, MD • Posted on June 29, 2018

The Bonus Years

As I’ve often said, if you are a woman over age 50, you’re living in the “bonus years.” You may ask why is it the bonus years? Because the female body, from a reproductive and hormonal standpoint, winds down after age 50.

Usually, by the sixth decade there is very little estrogen in a woman's system. Even though menopause can range from age 40 to age 58, the average age is about 52 years when the ovaries stop making eggs and thus estrogen rapidly declines. During this time women can experience the following:

Half of women may have symptoms with hot flashes.
Half of women lose bone.
Up to 80% of women over time lose vaginal lining, which results in a VERY THIN and dry vagina and some have marked changes in both the vagina and bladder, hence the interest in "vaginal rejuvenation".

Changes to the Vagina During Menopause

Dry and thin vagina happens because of the loss of estrogen hormones from the ovaries and also a likely loss of a precursor hormone (DHEA) production in the adrenal glands. Marked changes occur in the vaginal lining as well as the base of the bladder and the urethra. These changes may not cause any symptoms or they may cause serious symptoms like:

bladder irritability
overactive bladder
vaginal dryness
decrease in sensation
pain with any kind of sexual activity
vaginal laxity (especially in women who have had vaginal childbirth)
decreased ability to reach sexual climax

Many patients have described to me they feel like they’re sitting on “shards of glass” and can no longer wear jeans, ride their horse or even do regular activities due to the marked thinning. So keeping the vagina healthy is very important and is very dependent on hormone status as well as the state of the supportive tissue and the pelvic muscle tone.

Keeping A Healthy Vagina

As I often tell my patients, we don’t care what you do with your vagina, with who you do it with, or if you do anything at all sexually. However, keeping the tissue healthy reduces infection risk and keeps a healthy micro-biome.

By preventing painful situations one can avoid “vaginismus.” The term vaginismus means vaginal muscle spasm and this can cause the following:

pelvic pain
prevent sexual activity
can lead to bladder dysfunction

So we want to avoid any type of painful pelvic event because it can trigger a cascade of problems that last indefinitely without appropriate therapy. The best "rejuvenation" of a thin vagina is treating it topically with pharmaceutical therapies to improve the atrophy that results from hormone loss.

Local vaginal estrogen therapies

2 types of vaginal estrogen cream

Estrace® (bio-identical estradiol) cream and now FDA approved generic estradiol 0.01% available
Premarin® (conjugated estrogens) vaginal cream

Estrogen vaginal tablets

Vagifem® (bio-identical estradiol) 10mcg
Yuvafem (generic estradiol) 10 mcg

Estradiol vaginal ring

The Estring® vaginal ring is also bio-identical estradiol and lasts for three months and gives a continuous amount of vaginal estrogen and may give a mild lift to the bladder neck.

Estradiol vaginal Inserts

Imvexxy® 10 mcg
Imvexxy® 4 mcg

Vaginal DHEA

Intrarosa® - inserted vaginally nightly (and does not have to be refrigerated like the compounded version.) It contains NO estrogen, but allows just the genital tissue to make both estrogen and testosterone inside the cells of the genito-urinary tissue.

The new kid on the block... Imvexxy is Sexy!

The newest kid on the block to treat vaginal atrophy (genito-urinary syndrome of menopause) is Imvexxy®, which will be available for prescription therapy in late July 2018.

It is welcome to have a new option as in my many years of practice I have found that one size does not fit all.

It is bio-identical estradiol in coconut oil and has no applicator.

There is definitely different preferences as some women find creams to be messy, other women do not like to use an applicator and worry about the environment and some women especially, those with history of breast cancer or endometriosis have a sensitivity to estrogen and want to be able to use the lowest effective dose which is 4 mcg twice a week after a 2 week loading dose therapy.

Some general facts about Imvexxy

About the size of a tiny pearl.
Has bio-identical estradiol and comes in 2 very low doses of estrogen - in a 4 mcg and 10 mcg dose.
It is suspended in coconut oil and is bioadhesive.
There is no applicator, no mess, and can be inserted in the vagina at any time of day (does not have to be inserted at night).
Provides a new option for keeping the vagina healthy and moist and keeps systemic estrogen levels in the very low postmenopausal range.
It is used for a loading dose daily for 2 weeks, then twice weekly.

GSM Treatments

As with any of these therapies that treat genitourinary syndrome of menopause, a woman can have vaginal or oral sex, comfortably and not affect her partner while using any of these options. The amount of estrogen in vaginal secretions is much LESS than the estrogen levels present in menstruating and pregnant women. Not to mention the average male over age 50 has a higher estrogen blood level than the average postmenopausal woman not on systemic estrogen!

More Treatments for Pain During Sexual Activity

Non-estrogen oral option: Osphena® 60 mg daily with food. This is a good option for those wanting to avoid vaginal applications and/or who want to avoid estrogen.
Six vaginal estrogen options: Most are bio-identical estradiol while Premarin® (conjugated estrogen) cream has 10 different estrogens and is used twice weekly to treat atrophy and dyspareunia.
For women who have continued pain with sexual activity -dyspareunia - they may have vaginismus and need to see a female pelvic floor physical therapist for special pelvic floor therapy. Other women may have undiagnosed skin conditions like lichen sclerosis or lichen planus and need specific therapies for these conditions.

Vaginal estrogen use is safe, effective and has benefits beyond sex

Keep the vaginal tissue healthy also keeps bladder lining healthy which can reduce bladder infections and overactive bladder. Low dose vaginal estrogen is safe and effective. The North American Menopause society and others have petitioned the FDA to remove the boxed warning on vaginal estrogen as these warnings do not apply and unfortunately have scared many women away for safe and effective therapy.

The newest option, Imvexxy comes in the absolute lowest, effective dose of estrogen and provides a new option to keep the vagina healthy and moist. It is important to maintain treatment twice a week for the best outcome.

Beware About Vaginal Laser and Radiofrequency Heat Therapies

Because of fears and because not all women respond to local therapies, newer options are being pursued by women. Many women are used to facial and skin rejuvenation with lasers and heat facial therapies are naturally interested to see if these therapies can be applied to the genitals. Viveve® is a patented radiofrequency therapy which treats vaginal laxity and has a dual cooling and heating process that help trigger formation of collagen. Vaginal stimulating devices can increase muscle strength and tone and are an excellent non-surgical medical option to treat bladder leakage and some sexual dysfunction.

Pulsed radiofreqency heat with ThermiVa® to stimulate collagen support in the vagina and vulva may possibly be able to help with vaginal laxity and mild urge and stress urinary leakage. And so-called "vaginal rejuvenation” with the MonaLisa Touch® laser is currently being studied for effectiveness. However, the FDA has recently warned that vaginal lasers may cause scarring and burning and that companies should not market for "vaginal rejuvenation." The FDA has cited seven device manufacturers for inappropriate marketing of their devices for "vaginal rejuvenation" procedures. They are Alma Lasers, BTL Aesthetics, BTL Industries, Cynosure, InMode, Sciton, and ThermiGen.

In general, treatment with lasers, vaginal stimulating devices and vaginal probes, just like cosmetic dermatologic procedures, are NOT covered by insurance but paid out of pocket and do NOT have extensive testing.

However, most prescriptive vaginal estrogen and non-estrogen treatments with pills, tablets, creams, ring, suppositories and the new Imvexxy® vaginal insert treatment will usually have some prescription coverage.

So there should be no excuse not to keep your vagina healthy and happy!

Be Strong. Be Healthy. Be in Charge!

- Holly L. Thacker, MD

Holly L. Thacker, MD, FACP is nationally known for her leadership in women’s health. She is the founder of the Cleveland Clinic Specialized Women’s Health Fellowship and is currently the Professor and Director of the Center for Specialized Women’s Health at Cleveland Clinic and Lerner College of Medicine at Case Western Reserve University. Her special interests are menopause and related medical problems including osteoporosis, hormone therapy, breast cancer risk assessment, menstrual disorders, female sexual dysfunction and interdisciplinary women’s health. Dr. Thacker is the Executive Director of Speaking of Women’s Health and the author of The Cleveland Clinic Guide to Menopause.

monalisa touch, sexual function, vaginal pain, women's health, dr. holly l. thacker

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