Vaginal dryness (VD)

About

The vagina

The walls of the vagina.   Mucus-membrane covered muscles (normally in a relaxed state),  touching each other, with many folds (rugae) that provide a large surface for topical absorption of medications and enable the vagina to expand during intercourse and childbirth.

Estrogen supports a lubricated and thick vaginal lining.  The protective vaginal surface lining is mostly comprised of squamous epithelial cells. Estrogen is known to proliferate these cells and the layers below it to thicken the  vaginal wall.  Topical and systemic estrogen  increases membrane collagen content  and supports lubrication (increases mucopolysaccharides and hyaluronic acid)

Vaginal lubrication

Vaginal lubricating fluid.   Slightly acidic and travels slowly through the vagina removing dead cells, to keep the mucous membrane lining clean, supple and moist, supporting a healthy microflora. When the hormone progesterone peaks during the luteal (post-ovulation) phase, vaginal secretions turn cloudy or white. When estrogen is the dominant hormone (pre-ovulation), discharge tends to be clear, stretchy, or watery.

Lubricating fluid comes from 3 sources  (The vagina itself does not contain lubricating glands)

1. Produced by glands at the cervix

 (at neck of womb)

Cervical mucus is secreted by epithelial cells lining the cervix to facilitate sperm travel to the uterus and remove microbes. Predominantly composed of water and mucins, dervical mucus also contains high levels of immuno-active proteins such as immunoglobulin A (IgA), lactoferrin and lysozyme which protect against infection by blocking adhesion and mediating microbial killing. Additionally, some vaginal lubrication originates from the uterus.

2. Ultrafiltrated blood

( from the vaginal capillaries)   

Fluid is composed of water and small proteins combined with dead epithelial cells from the vaginal lining. Sufficent blood pressure in the pelvic area, requiring the bioavailability of nitric oxide (NO),   pushes this lubricating fluid from the capillaries through intracellular gap junctions between vaginal epithelial cells.   Gaseous NO is produced in capillary endothelia to induce vasodilation and its production depends on the enzyme NO synthase (eNOs), which is enhanced by steroid hormones, most notably estrogens: Estriol and Estradiol, and is decreased by hyperglycemia.  Since an inflammatory environment invokes feedback mechanisms in the body to suppress high NO production (which can increase production of free radicals), low inflammatory conditions are more conducive to supporting the bioavailability of NO in facilitating vaginal lubrication.

3.the two Bartholin’s glands and the Skene glands

 (at the entrance of the vagina)

Extra moisture is provided by these glands when stimilated by sexual excitement for sexual intercourse.

Who experiences vaginal dryness? 

Vaginal dryness is common during and after menopause.   Can be a symptom of vaginal atrophy (a thinning and loss of elasticity of the vaginal lining and shortening of vaginal canal).  A consequence of hormonal changes, usually a disproportionate complete loss of PROGESTERONE compared to only ~40% drop in estrogen - termed estrogen dominance.

Vaginal dryness is also experienced by reproductive age women.   E.g. 17% of women aged 18-50 during sex. Womens Health Concern, 2020 )

Vaginal dryness is especially prevalent in pre-menopausal women with low levels of estrogen.   E.g. breastfeeding mothers, those who have had ovaries removed or received chemotherapy, which can damage ovaries.

Causes of vaginal dryness

Dehydration

Water - 2/3 of you!

Low estrogen levels

May be due to:

•  Menopause - estrogen levels decrease with age

•  Severe stress and/or depression.  

•  Anti-estrogen / estrogen-lowering medications - such as antidepressants: fluoxetine (Prozac) and sertraline (Zoloft). use of nuvaring for birth control.

•  Thyroid disorders

•  Polycystic ovary syndrome (PCOS)

•  Low functioning pituitary gland

•  Low body weight

•  Excessive exercise

•  Stopping estrogen-based birth control (BC).  The body reduces estrogen production to adjust to exogenous estrogen in BC. Estrogen levels may be low until the body readjusts its production levels after stopping BC.

•  Chemotherapy

•  Radiation to pelvic area

•  Smoking

•  Removal of ovaries / Ovarian insufficiency

•  Chronic kidney disease

•  Post childbirth / breast-feeding

Stress => Low PROGESTERONE levels

All kinds of stress (such as anger, anxiety, depression, trauma, sleep deprivation, over-exercising, nutrient deficiencies . . . you name it!) promote production of stress-related hormones by the "stress management" adrenal glands, namely the neurotransmitter adrenaline (epinephrine), and glucocorticoids, such as CORTISOL, to induce "fight or flight" mechanisms to cope with the stress.

The steroid hormone Progesterone is the raw material used to produce the glucocorticoids, such as Cortisol, as well as the mineralocorticoids, such as ALDOSTERONE (a hormone which balances water and salt in the body), DHEA hormone (the precursor to both the male and female sex steroid hormones, and the neurotransmitter NOREPINEPHRINE.

 Chronic (ongoing) stress can both deplete the body's available PROGESTERONE and also cause adrenal fatigue, which then decreases production of ALDOSTERONE (and other mineralocorticoids) and CORTISOL (and other glucocorticoids). ALDOSTERONE promotes water retention and swelling, and although a building block of ALDOSTERONE, PROGESTERONE blocks ALDOSTERONE receptors, thereby promoting normal fluid loss and decreasing swelling.

PROGESTERONE:

•  increases Epidermal growth factor-1 (EGF-1) - which plays a vital role in the production of collagen, elastin, and hyaluronic acid for epithelial / epidermal growth - needed to prevent vaginal atrophy. EGF has estrogen-like effects in the promotion of cell growth in the reproductive tract and EGF may serve as an important mediator of estrogen action in vivo.  PubMed mice study

•  Optimizes libido/restores normal sexy feelings;

•  Is calming and anti-depression.    In the brain,  PROGESTERONE activates receptor sites for GABA, an inhibitory neurotransmitter, which decreases anxiety and depression. (Anti-depressants and barbituates bind these same receptors).  PROGESTEROne also raises SEROTONIN hormone levels in brain;

Functions of PROGESTERONE in the body

Medications that can dry vaginal membranes

Antidepressants

Antidepressants SSRIs (E.g. Prozac) and/or SNRI's (E.g. Cymbalta) have been shown to cause vaginal dryness, decreased genital sensations, decreased libido, and difficulty achieving orgasm

Post-SSRI/SNRI Sexual Dysfunction (PSSD).

Newly recognized by some as iatrogenic (caused by medication or medical treatment),  described as a long-term (months /years) after-effect of taking SSRI's or SNRI's.   Well-referenced article     Another article   Canadian PSSD Society 

SNRI's (Serotonin and norepinephrine reuptake inhibitors).

Used to increase the presence of the hormonal neurotransmitters SEROTONIN and NOREPINOPHRINE (aka NORADRENALINE, released by adrenal glands atop the kidneys).  Side-effects of SNRIs are  mouth and vaginal dryness and reduced libido.

E.g. Cymbalta (duloxetine).   This SNRI drug is used to treat depression, anxiety, and certain nerve or muscle pain conditions. Duloxetine INCREASES estrogen levels. Interestingly, the FDA warns that one of its side-effects is to cause suicidal tendencies, especially in younger people. 

SSRI's (Serotonin reuptake inhibitors).

 Used to increase the presence of the hormonal neurotransmitter SEROTONIN. SNRI's are used to increase the presence of the hormonal neurotransmitters SEROTONIN.

E.g.  Prozac (fluoxetine) and Zoloft (sertraline). These drugs are used to treat depression, obsessive-compulsive disorder (OCD), panic attacks, post-traumatic stress disorder (PTSD), and social anxiety. Twoof the side-effects of SSRI's are to DECREASE estrogen and cause mouth and vaginal dryness.

Imbalanced vaginal microbiome / pH

A healthy vaginal state is usually dominated by Lactobacillus, low diversity of anaerobic bacteria, and a balanced vaginal immune system (e.g. pro-inflammatory and anti-inflammatory cytokines).

Vaginal microbiota and the potential of Lactobacillus derivatives in maintaining vaginal health

The Lactobacillus bacterial species dominates the normal vaginal flora.  They metabolize the high concentration of glycogen in vaginal epithelial cells into lactic acid, which (1) helps maintain the healthy acidic pH of 3.5 to 4.5 in the vagina and (2) produce antimicrobial substances, to discourage the growth of pathogenic microorganisms which can cause vaginal infections, such as UTI's and bacterial vaginosis (BV).   Estrogen stimulates the epithelial cells lining the vaginal walls to produce glycogen, a food source for Lactobacillus.

The most common species found in the vagina are Lactobacillus crispatus, L. gasseri, L. iners, and L. jensenii.  Most probiotics and yogurt contain other species, such as L. rhamnosus or L. acidophilus (more common in the gut).

Aerobic vaginitis (AV) is a form of vaginitis characterized by a some level of disruption of the usual lactobacilli flora, combined with inflammation, atrophy and the presence of predominantly aerobic microflora (Staphylococcus aureus and Escherichia coli), some possibly pathogenic. Sometimes AV presents a yellow discharge with AV.

Contact dermatitis 

Causes an itchy rash - look for any change that may be the culprIt, possibly causing an allergic reaction:

Vaginal lubricants and spermicides; latex condoms / diaphragms; Scented toilet paper, shampoos and body wash, fabric softeners, laundry detergent, tampons and sanitary pads.

Sjögren’s syndrome

This autoimmune condition affects mainly women aged 40 - 60, damages the body’s secretory glands preventing tears and saliva, as well as secretions of the vagina and gastrointestinal tract.

Women are more susceptible to auto-immune diseases than men. A study using mice found that increased autoantibody production in females can be attributed to the effect of estrogen on the immune response. PubMed  PubMed

Many lifestyle changes, including stress or nutrient deficiencies / excesses can result in an Imbalance between hormones - major ones being estrogen, testosterone, progesterone, cortisol, insulin, and thyroid. Even a slight imbalance between these hormones can lead to inflammation, cell dysfunction, and tissue damage --- all contributing factors in autoimmune conditions. 

Miscellaneous

Soaps, laundry detergents, lotions, perfumes, or douches in vagina.  Can exacerbate irritation

UTIs, Yeast infection

Treatments to aid vaginal lubrication

HYDRATE / DRINK WATER

Relieve stress

Successful non-drug techniques to use include: SOTA Bio-Tuner and Meridian Tapping Technique

Personal habits

Wear loose pants or dresses and soft cotton underwear

Avoid perfumed soaps when washing the vaginal area

Increase estrogen presence in vaginal lining

LOW DOSE topical natural estrogen (applied to vaginal membranes) - The dose should be low enough to have only localized effects. Systemic estrogen is not advised, since it enters the blood and can cause hormonal imbalance in the body. Also TESTOSTERONE and/or  DHEA may be appropriate.

Maintain a healthy gut microbiome.     In vitro analysis demonstrated the ability of 35 bacterial enzymes in the human gut to reactivate two distinct estrogen glucuronides (estrone-3-glucuronide and estradiol-17-glucuronide) to estrone and estradiol, allowing estrogens to be reabsorbed into the body instead of exiting via the gut. PubMed

Increase NO presence in vaginal capillaries to increase blood flow

The main factors involved in eNOS activity (the enzyme promoting nitric oxide (NO) production and increased blood flow) include estrogens (Estriol or estradiol), phyto-estrogens in soy products / flaxseed, testosterone, some medicines, vitamins and supplements, niacin (B3), calcium, ginseng, and ACE inhibitors (ACE-i).

Vitamins / Nutrients

Vitamin A - helps moisture content and collagen production for mucous membranes

Vitamin B-Complex (50mg / day)

Vitamin E -  aids hydration - topical application of vit E suppositories, supplement natural mixed-tochopherols  or consume E in sunflower and pumpkin seeds;

Omega-3  - Daily: 2 Tbsp. flax seed (grind and consume within 20 minutes) + 1 Tbsp. quality flax oil (E.g. Flora,  Spectrum) made water-soluble by first mixing with 1 Tbsp. whey protein powder OR 2 Tbsp. cottage cheese OR 3 Tbsp yogurt. Can add to blender drink or use your imagination. It must not be heated above about 110 deg. F.

Omega-7 - Sea buckthorn oil; topical application to vaginal membranes

Calcium - required for eNOS enzyme, used to convert L-arginine to NO and increase blood flow.  Calcium in green leafy vegetables, dairy products, nuts

L-Arginine - this amino acid is the raw material for NO production. Foods HIGH IN L-ARGININE include: nuts (almonds, walnuts, hazelnuts), berries, chocolate, beans, fish, chicken, sunflower and flax seed

Probiotics

Take orally or topically to support the vaginal microbiome via the gut microbiome. Probiotics are usually freeze-dried and lactic acid species such as Lactobacillus are generally susceptoble to temperatures above 50C (122F). Study link

Topically, insert contents of probiotic capsule mixed with ???? into the vagina for localized benefits. Or insert active Lactobacillus-containing yogurt at night whilst laying flat (can also make frozen suppositories).

improving lubrication throughout the body – including tears, saliva, and vaginal secretion. You can start with 1 pill (0.5 g) twice a day with meal. If you do not feel any discomfort like upsetting stomach, you can increase to 2 pills (1 g) twice a day for the first month to boost the recovery. After 1 month, you can take 2 pills a day for health maintenance as suggested on the bottle

We report here the antimicrobial activities of two commercially existing Lactobacillus strains, Lactobacillus rhamnosus HN001 and Lactobacillus acidophilus GLA-14 strains and their combination (Respecta® probiotic blend) against four different pathogens responsible for both bacterial vaginosis (Gardenerella vaginalis and Atopobium vaginae) and aerobic vaginitis (Staphylococcus aureus and Escherichia coli) 

not all lactobacilli or probiotic strains are effective in the vagina. A commercial probiotic strain, L. rhamnosus GG, is apparently not well suited to colonizing the vagina nor is L. acidophilus, perhaps explaining why both these strains failed to prevent recurrence of UTI [25,26]. Further studies are required to understand this difference in functionality between strains.

In summary, L. fermentum RC-14 and L. rhamnosus GR-1 represent the first probiotic combination taken orally to reduce vaginal colonization by pathogenic bacteria and yeast. Daily intake of scientifically selected probiotics could provide a natural, safe and effective means to stabilize the fluctuating vaginal flora and thereby lower the risk of infections in healthy women as well as those prone to urogenital disease.

References

Myrtle Wilhite MD, MS, in Integrative Medicine (Fourth Edition), 2018