by Dragana Skokovic-Sunjic BSc (Pharm)
One of the topics we as pharmacists could/should get more involved in is vaginal health.
I can tell your eyes are popping out as you are reading this: What is she talking about now? I can not start this conversation; I do not know even why this would be my responsibility any way?!
Let’s break it down step by step.
Vaginal health, at any point in our lives and especially in menopause, is a multifaceted issue. The term ‘vagina’ is used to describe the part of the female anatomy connecting the uterus with the outside world. Any changes, deterioration, or injury to this tissue could lead to increased risk of conditions such as vaginal atrophy, increased risk of developing chronic conditions such as Lichen sclerosis, increased risk of malignant changes, urinary incontinence, bladder prolapse, or uterine prolapse requiring surgery and long-term supportive therapy. It really does not have to be limited to the ability to engage in or enjoy intercourse. There – I mentioned several potentially censorable words many times… keep reading, it will get better and even juicier.
So, let’s drop the outdated ‘vagina’ terminology and let’s use an updated term, endorsed by North American Menopause Society and now accepted globally: GSM or Genito-Urinary Syndrome of Menopause. The genitourinary syndrome of menopause encompasses bothersome vaginal atrophy along with urinary symptoms. GSM symptoms may significantly affect the quality of life, sexual satisfaction, and relationships. Unlike hot flashes, which generally improve with time, vaginal symptoms typically worsen with time because of aging and a prolonged lack of estrogen. Vaginal dryness is a health issue that can surface at any age, making everything from sex to any activity, such as sitting and even wearing your favourite pair of jeans, uncomfortable.
This is a list of possible changes affecting the tissue in ‘that’ area:
- Vaginal mucosal lining becomes thin, dry, and less elastic, with decreased secretions and lubrication
- Fragile, dry, inflamed vaginal tissues may tear and bleed
- Vaginal infections increase (as the healthy acidic pH of the vagina becomes more alkaline)
- Discomfort with urination and increased urinary tract infections can occur
- Women receiving cancer treatments may have additional injury to the vaginal tissues from chemotherapy or pelvic radiation
- Aromatase inhibitors, taken by many women with breast cancer, resulting in extremely low estrogen levels, often causing severe symptoms in that area
- Women with discomfort from vaginal atrophy often engage in less frequent intercourse or other sexual activity, which can cause the vagina to become shorter, narrower, and less elastic
- Pain, narrowing of the vagina, and involuntary tightening of vaginal and pelvic muscles (known as vaginismus) can intensify to the point where sexual intercourse or other sexual activity is no longer pleasurable or even possible. In older women with discomfort and pain, we often have to use opioids for pain relief, because the issue was not treated before it was too late.
While 100 percent of women experience vaginal atrophy as they age, very few seek medical advice. Global studies indicate that only 7 percent of women actually do receive medical treatment for vaginal dryness and related symptoms. And, that’s unfortunate because there are safe and effective treatments available.
Bothersome symptoms always vary from woman to woman. When it comes to dryness, many people assume distress only means one thing – painful sexual intercourse. Common taboos and the belief that ‘we do not talk about it’ prevent women from asking for help from reliable resources (pharmacists included). Generally, women tend to be proactive about their health and wellbeing, but as far as vaginal health is concerned, it’s still a taboo subject; these women are normally very straightforward and not shy to ask about any other aspect of their health.
As healthcare providers, it is one of our responsibilities to make sure that we are empowering women with the right information, and that women feel comfortable and safe with us and are given opportunities to ask questions.
A vocal women’s health advocate, Dr. Marla Shapiro states: ‘I want to get rid of the myth that dry vaginas are a natural part of aging, and you just have to accept it.’
If our patients do not talk to us about it, if we do not start that conversation, they might resort to getting information from Dr. Google, or from peddlers of pseudo-scientific gimmicks. And those offers for miracle cures are everywhere, as the global wellness industry tops $4.2 trillion today. One recent example is infamous Gwyneth Paltrow Goop’s $66 jade ‘yoni’ eggs, said to increase ‘vaginal muscle tone’ and ‘hormonal balance.’ In September 2018, Goop was forced to pay $145,000 in civil penalties to settle a consumer protection lawsuit brought by prosecutors in 10 California counties over three of its products, including its ‘yoni’ jade and rose quartz vaginal eggs.
Canadian health law and policy professor Timothy Caulfield, author of the book Is Gwyneth Paltrow Wrong About Everything?, said the settlement sent ‘a powerful message’ about the type of information found on sites like Goop, calling it ‘a little victory for science.’
In August 2019, another Canadian-born specialist, Jennifer Gunter, an OB-GYN with nearly three decades of experience, published a new book, The Vagina Bible: The Vulva and the Vagina—Separating the Myth From the Medicine. Dr. Gunter states she is on a mission to arm women with science-based advice in hopes of stanching the spread of health misinformation.
The bottom line is, it seems that everyone is talking about this topic, except those of us with the best knowledge and opportunity to provide science-based, safe and effective treatment. And those treatments often do not even require a prescription.
Try getting familiar with vaginal moisturizers in your pharmacy, get a few samples so you can engage in better-informed conversation. Know the difference between gels, ointments, vaginal ovules; do not be timid to ask what the patient preference is.
Keep all of this in mind next time you dispense aromatase inhibitor, or now commonly prescribed SGLT2 inhibitors. Ask about it, ask about itch and discomfort ‘you know where’…
I understand there are barriers and cultural beliefs when mentioning unmentionables. Many years ago, I had a pharmacy technician who was a very nice older lady who could not say ‘vagina’ or anything ‘vaginal’ to save her life. If she was approached by a patient and needed to tell me someone had a question about vaginal itch, she would pause, look at me with eyes wide open and nod vigorously, without ever saying ‘vaginal’. It became like an unspoken code in our pharmacy and we learned how to function without forcing her to say it.
Come to think of it, if this was the case for our pharmacy technician, someone working in healthcare, how many of our patients might have similar issues and barriers to start talking about it?
We need to work on normalizing this conversation.
We need to start talking about it as if we are talking about skin health, oral health, overall health.
It is not always about sex.
Not everything is about sex.
…But you have to admit having sex in the title made you read this article.
Dragana Skokovic-Sunjic BSc (Pharm) is a clinical pharmacist with Hamilton Family Health Team and a NAMS Certified Menopause Practitioner. She is also a leader in knowledge mobilization for probiotics in Canada and the United States
Dragana Skokovic-Sunjic presented recently at Pharmacy U Toronto. For more information, visit Pharmacy U