By Tara Bahrampour
[W]hen the FDA approved Viagra in 1998 to treat erectile dysfunction, it changed the sexual landscape for older men, adding decades to their vitality. Meanwhile, older women with sexual problems brought on by aging were left out in the cold with few places to turn besides hormone therapy, which isn’t suitable for many or always recommended as a long-term treatment.
Now, propelled by a growing market of women demanding solutions, new treatments are helping women who suffer from one of the most pervasive age-related sexual problems.
Genitourinary syndrome, brought on by a decrease in sex hormones and a change in vaginal pH after menopause, is characterized by vaginal dryness, shrinking of tissues, itching and burning, which can make intercourse painful. GSM affects up to half of post-menopausal women and can also contribute to bladder and urinary tract infections and incontinence. Yet only 7 percent of post-menopausal women use a prescription treatment for it, according to a recent study.
The new remedies range from pills to inserts to a five-minute laser treatment that some doctors and patients are hailing as a miracle cure.
The lag inaddressing GSM has been due in part to a longstanding reluctance among doctors to see post-menopausal women as sexual beings, said Leah Millheiser, director of the Female Sexual Medicine Program at Stanford University.
“Unfortunately, many clinicians have their own biases and they assume these women are not sexually active, and that couldn’t be farther from the truth, because research shows that women continue to be sexually active throughout their lifetime,” she said.
With today’s increased life expectancy, that can be a long stretch – another 30 or 40 years, for a typical woman who begins menopause in her early 50s. “It’s time for clinicians to understand that they have to bring up sexual function with their patients whether they’re in their 50s or they’re in their 80s or 90s,” Dr. Millheiser said.
By contrast, doctors routinely ask middle-aged men about their sexual function and are quick to offer prescriptions for Viagra, said Lauren Streicher, medical director of the Northwestern Medicine Center for Sexual Medicine and Menopause.
“If every guy, on his 50th birthday, his penis shriveled up and he was told he could never have sex again, he would not be told, ‘That’s just part of aging,’” Dr. Streicher said.
Iona Harding of Princeton, New Jersey, had come to regard GSM, also known as vulvovaginal atrophy, as just that.
For much of their marriage, she and her husband had a “normal, active sex life.” But after menopause sex became so painful that they eventually stopped trying.
“I talked openly about this with my gynecologist every year,” said Mrs. Harding, 66, a human resources consultant. “There was never any discussion of any solution other than using estrogen cream, which wasn’t enough. So we had resigned ourselves to this is how it’s going to be.”
It is perhaps no coincidence that the same generation who first benefited widely from the birth control pill in the 1960s are now demanding fresh solutions to keep enjoying sex.
“The Pill was the first acknowlegement that you can have sex for pleasure and not just for reproduction, so it really is an extension of what we saw with the Pill,” Dr. Streicher said. “These are the women who have the entitlement, who are saying ‘Wait a minute, sex is supposed to be for pleasure and don’t tell me that I don’t get to have pleasure.’”
The push for a “pink Viagra” to increase desire highlighted women’s growing demand for sexual equality. But the drug flibanserin, approved by the FDA in 2015, proved minimally effective.
For years, the array of medical remedies has been limited. Over-the-counter lubricants ease friction but don’t replenish vaginal tissue. Long-acting mosturizers help plump up tissue and increase lubrication, but sometimes not enough. Women are advised to “use it or lose it” – regular intercourse can keep the tissues more elastic – but not if it is too painful.
Systemic hormone therapy that increases the estrogen, progesterone, and testosterone throughout the body can be effective, but if used over many years it carries health risks, and it is not always safe for cancer survivors.
Local estrogen creams, suppositories or rings are safer since the hormone stays in the vaginal area. But they can be messy, and despite recent studies showing such therapy is not associated with cancer, some women are uncomfortable with its long-term use.
In recent years, two prescription drugs have expanded the array of options. Ospemifene, a daily oral tablet approved by the FDA in 2013,activates specific estrogen receptors in the vagina. Side effects include mild hot flashes in a small percentage of women.
Prasterone DHEA, a naturally occurring steroid that the FDA approved last year, is a daily vaginal insert that prompts a woman’s body to produce its own estrogen and testosterone. However, it is not clear how safe it is to use longterm.
And then there is fractional carbon dioxide laser therapy, developed in Italy and approved by the FDA in 2014 for use in the U.S. Similar to treatments long performed on the face, it uses lasers to make micro-abrasions in the vaginal wall, which stimulate growth of new blood vessels and collagen.
The treatment is nearly painless and takes about five minutes; it is repeated two more times at 6-week intervals. For many patients, the vaginal tissues almost immediately become thicker, more elastic, and more lubricated.
Mrs. Harding began using it in 2016, and after three treatments with MonaLisa Touch, the fractional CO2 laser device that has been most extensively studied, she and her husband were able to have intercourse for the first time in years.
Cheryl Edwards, 61, a teacher and writer in Pennington, New Jersey, started using estrogen in her early 50s, but sex with her husband was painful and she was plagued by urinary tract infections requiring antibiotics, along with severe dryness.
After her first treatment with MonaLisa Touch a year and a half ago, the difference was stark.
“I couldn’t believe it… and with each treatment it got better,” she said. “It was like I was in my 20s or 30s.”
While studies on MonaLisa Touch have so far been small, doctors who use it range from cautiously optimistic to heartily enthusiastic.
“I’ve been kind of blown away by it,” said Dr. Streicher, who, along with Dr. Millheiser, is participating in a larger study comparing it to topical estrogen. Using MonaLisa Touch alone or in combination with other therapies, she said, “I have not had anyone who’s come in and I’ve not had them able to have sex.”
Cheryl Iglesia, director of Female Pelvic Medicine & Reconstructive Surgery at MedStar Washington Hospital Center in Washington D.C., was more guarded. While she has treated hundreds of women with MonaLisa Touch and is also participating in the larger study, she noted that studies so far have looked only at short-term effects, and less is known about using it for years or decades.
“What we don’t know is is there a point at which the tissue is so thin that the treatment could be damaging it?” she said. “Is there priming needed?”
Dr. Millheiser echoed those concerns, saying she supports trying local vaginal estrogen first.
So far the main drawback seems to be price. An initial round of treatments can cost between $1,500 and $2,700, plus another $500 a year for the recommended annual touch-up. Unlike hormone therapy or Viagra, the treatment is not covered by insurance.
Some women continue to use local estrogen or lubricants to complement the laser. But unlike hormones, which are less effective if begun many years after menopause, the laser seems to do the trick at any age. Dr. Streicher described a patient in her 80s who had been widowed since her 60s and had recently begun seeing a man.
It had been twenty years since she was intimate with a man, Dr. Streicher said. “She came in and said, ‘I want to have sex.’” After combining MonaLisa Touch with dilators to gradually re-enlarge her vagina, the woman reported successful intercourse. “Not everything is reversible after a long time,” Dr. Streicher said. “This is.”
But Dr. Iglesia said she has seen a range of responses, from patients who report vast improvement to others who see little effect.
“I’m confident that in the next few years we will have better guidelines (but) at this point I’m afraid there is more marketing than there is science for us to guide patients,” she said. “Nobody wants sandpaper sex; it hurts. But at the same time, is this going to help?”
The laser therapy can also help younger women who have undergone early menopause due to cancer treatment, including the 250,000 a year diagnosed with breast cancer. Many cannot safely use hormones, and often they feel uncomfortable bringing up sexual concerns with doctors who are trying to save their lives.
“If you’re a 40-year-old and you get cancer, your vagina might look like it’s 70 and feel like it’s 70,” said Maria Sophocles, founding medical director of Women’s Healthcare of Princeton, who treated Mrs. Edwards and Mrs. Harding.
After performing the procedure on cancer survivors, she said, “Tears are rolling down from their eyes because they haven’t had sex in eight years and you’re restoring their femininity to them.”
The procedure also alleviates menopause-related symptoms in other parts of the pelvic floor, including the bladder, urinary tract, and urethra, reducing infections and incontinence.
Ardella House, a 67-year-old homemaker outside Denver, suffered from incontinence and recurring bladder infections as well as painful sex. After getting the MonaLisa Touch treatment last year, she became a proslyter.
“It was so successful that I started telling all my friends, and sure enough, it was something that was a problem for all of them but they didn’t talk about it either,” she said.
“I always used to think, you reach a certain age and you’re not as into sex as you were in your younger years. But that’s not the case, because if it’s enjoyable, you like to do it just as much as when you were younger.”
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