We have been learning how important estrogen is throughout a woman’s life stages and that times of high or low estrogen may be problematic. When it comes to vaginal health and function, periods of low estrogen can be issue for some women.
Estrogen is low in the immediate post-partum period if breastfeeding, due to presence of prolactin which opposes its production. Peri-menopausal women have fluctuating high to low estrogen, and post-menopausal woman have low estrogen.
Estrogen helps increases collagen production and lubrication of vaginal tissues – with no or low levels, vaginal tissues can be dry and thin, are easily irritated, and more prone to prolapse of the anterior or posterior walls. Collagen is a protein-based substance that gives structure to muscles and connective tissues in the body including the pelvic floor muscles and fascia. More estrogen means more collagen and more support for the pelvic organs such as the uterus, bladder, and rectum.
Estrogen is also a vaso-dilator (relaxes blood vessels) and it is thought can have a role to play in stress urinary incontinence by increasing blood supply to the internal urethral sphincter. Adequate sphincter blood supply aids closing pressure and helps to maintain continence with things like coughing and sneezing.
There are also emerging animal studies that are showing nerve regeneration with the use of estrogen, which is pretty exciting.....so watch this space!
Estrogen supplements in the form of vaginal pessaries or creams help to strengthen and plump up the tissues, may be prescribed to assist with bothersome symptoms such as dyspareunia (painful intercourse), tendency to infections (vaginal or urinary tract), or pelvic organ prolapse. Vaginal estrogen supplements are low dose estrogen – higher doses don’t work as well and hormone therapy such as estrogen patches for the skin, or tablets taken by mouth do not have the same effect on the vaginal tissues.
Estrogen is also used conjunction with treatment options such as pessaries. Pessaries are silicone medical devices, which are inserted inside the vagina and used to support the pelvic organs. It is an important part of pessary management to monitor the vaginal tissue for abrasions. Estrogen is used keep the tissue lubricated to prevent tissue trauma. Pessaries are prescribed by gynaecologist or women’s health physiotherapists with training to fit them.
It's important to note that supplemental estrogen is not an appropriate treatment for everyone and if often used in conjunction with many other treatment and lifestyle options. Not all women need it either. It's important to speak to your treating medical provider to see if it could be suitable for you. As Physiotherapists we work in collaboration with GPs and specialists to advise that it may be helpful, but cannot prescribe it ourselves.
Vaginal estrogen options are typically:
Vagifem low which is 10mcg of estradiol (E2) as a tablet inserted into the vagina
Ovestin cream which is 1mg/g estriol (E3) inserted into vagina or used on the vulva/vaginal entrance only
Ovestin 500mcg of estriol (E3) as a tablet inserted into the vagina
These usually start with loading doses of daily for 2 weeks followed by 1-2 x weekly but should always be guided by the prescribing doctor
Options for vaginal dryness that are not prescribed estrogen can include:
Essential fatty acids such as sea buckthorn oil e.g. VeeForMe Plump **
Fennel essential oil in olive oil e.g VeeForMe Smoothe **
Oil based moisturisers such as Olive and Bee (beeswax and olive oil) **
pH adjusted water based vaginal moisturisers - need to be acidic to suit the ideal vaginal environment
**available at Balance Health
Please note, oil-based applications are not suitable if trying to conceive or using condoms for contraception. Advice regarding vaginal applications is best made in collaboration with your practitioner, based on a pelvic physiotherapy consultation.
Casey Cleeland, Kara Cassells and Kristine Miles are available for pelvic health consultations at Balance Health. Casey is also trained to fit vaginal support pessaries and Kristine is also trained in management of the vaginal microbiome.