I have a patient who is asking about alternatives to vaginal lubricants. She is hormone-receptor positive, and commercially available creams have estrogen in them. What can I suggest to her? —name withheld on request

Vaginal dryness due to atrophy is a common complaint in postmenopausal women, often resulting in itching, irritation, and painful intercourse. Estrogen therapy is often the recommended treatment; however, for women with contraindications to hormone therapy, safe and effective alternatives to estrogen therapy are available. 

Symptoms of vaginal dryness can be managed by regular use of a vaginal moisturizer with supplemental use of vaginal lubricants for sexual activity. Vaginal moisturizers are water-based, nonhormonal gels designed for regular use (two or three times per week) to maintain or replenish vaginal moisture. Examples of over-the-counter brands are Replens and Vagisil Feminine Moisturizer. 

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In addition to regular use of a moisturizer, a vaginal lubricant used immediately prior to sexual activity can increase comfort. There are many over-the-counter products available, including Astroglide and KY Jelly, which are water-soluble. There are also many oil-based and silicone-based agents on the market, which may last longer and provide more effective relief during intercourse. Orally administered or locally applied vitamin E in daily doses of 100-600 IU has been found to increase vaginal lubrication, along with coconut oil, which contains caprylic acid to help stave off yeast infections. It should be noted, however, that oil-based lubricants may break down the latex in condoms and diaphragms. 

For women who have painful intercourse that is not easily relieved with moisturizers and lubricants, the use of graduated vaginal dilators may be helpful in reestablishing elasticity to the vaginal tissue over time. Vaginal dilator use can be taught to women by a clinician or pelvic physical therapist.   

In women with estrogen-dependent cancers and severely symptomatic vaginal atrophy that fails to respond to nonhormonal options, vaginal estrogen replacement may be considered, but this should always be discussed with your oncologist. And always see your doctor with any complaint of abnormal vaginal bleeding, abnormal vaginal discharge or odor, or new/concerning lesions.