Why DHEA Is Optimal For Vaginal Dryness, Pain And Pelvic Health

Please feel free to provide the link to this article to your friends and loved ones (and your doctor, too).

Too many women suffer from vaginal dryness, pain and pelvic health issues.

With aging, menopause, and hormonal changes, some 75% of post-menopausal women suffer from vaginal atrophy (1) which can include:

● vulvar-vaginal thinning and irritation

● uncomfortable intercourse due to excessive vaginal dryness

● increased vaginal and bladder infections (due to decreased normal flora, loss of lactobacilli and increased pH)

● leaking urine

● increased skin disorders affecting the urogenital tract (vulvodynia, vestibulitis, hypertrophic dystrophy, dermatitis, lichen sclerosis)

● decreased desire, arousal, and orgasm

● pelvic prolapse symptoms such as pressure and trouble eliminating

Younger women can experience these symptoms as well.

This article will discuss the vaginal atrophy symptoms women experience and will present a comparison of current treatment options. I also talk about the use of DHEA; in particular the scientific research and clinical findings that point to its effectiveness and safety.

“During peri-post menopause, women experience declining hormone levels including estrogen, progesterone, testosterone, and DHEA”

Before menopause, a woman’s ovaries produce many of her sex hormones, including estrogen. This female hormone maintains the health and integrity of the vaginal lining. During peri-post menopause, women experience declining hormone levels including estrogen, progesterone, testosterone, and dehydroepiandrosterone (DHEA).

Over time, women’s ovaries gradually decrease producing these hormones, causing vaginal lining shrinkage and drying due to decreased healthy secretions. Muscle loss also occurs. The lining becomes less elastic and thin, causing irritation and discomfort. The ovaries predominantly stop producing estrogen after menopause.

These and the other symptoms women experience from these decreasing hormones are life-affecting:

Yet only 20% To 25% of symptomatic women having vaginal atrophy seek medical treatment! (8) 

Woman looking at test results with her female doctor Lack of reporting symptoms to a doctor can be due to embarrassment, and/or a lack of awareness of vaginal health or treatment options. Women cannot readily examine their vulva or vagina (although you can with a mirror, here’s how), and can’t see the tissue changes that are otherwise easily visible to a physician. A physician can see extreme tissue changes in terms of color (pale or red), dryness, thinning and irritation (red or raw patches).

Women may also mistake their symptoms for common irritations, allergies or infections. More often the changes are so gradual, that the symptoms go unnoticed until there is pain, discharge, or incontinence.

“Unlike hot flashes which usually end even without treatment, vaginal atrophy symptoms usually increase in severity over time.”

The current life expectancy for American women is greater than 80 years old (as benchmarked in 2010 census data) and continues to increase. Given the average age of menopause, onset is 50.5 years, it is estimated that women may expect to live almost 40% of their entire lives after menopause in this discomfort and decreased quality of life.(9)

Unlike hot flashes which usually end even without treatment, vaginal atrophy symptoms usually increase in severity over time. (10)

Decreasing hormones are also an important clinical health issue beyond vaginal health. Hot flashes, bone loss, fat accumulation, loss of muscle mass and strength (11), memory loss, cardiovascular disease, and type 2 Diabetes are additional concerns. (12)

While helpful for lubrication these products are primarily cosmetic and do not treat underlying concerns. They may help with irritation and painful intercourse due to reducing dryness.

• Water-based lubricants include: K-YJelly, FemGlide, Summer’s Eve and others, and are non-staining. Silicone-based lubricants include Pink, Pure Pleasure and others.

• Oil-based lubricants include using mineral oil, petroleum jelly or baby oil. These are not recommended as they can actually cause irritation and have also been associated with high rates of latex condom breakage.

• Vaginal moisturizers include Replens, Moist Again, Fresh Start and K-Y Liquibase.

Natural solutions such as organic coconut oil, Ayurveda ghee (combined with herbs) and yes (an OTC organic lubricant) are also available and do not contain the additional chemicals that can be seen in other commercial lubricant and vaginal moisturizing solutions. These solutions can be enjoyable to use but offer little long-term relief. They offer temporary moisturizing, which may help with some pain during intercourse…but do nothing for pelvic health, incontinence or longer-term healing.

You can find out more info on lubricants and moisturizers here in my quick guide.

A number of OTC herbal remedies are available containing black cohosh, soy isoflavones, magnolia bark, and other ingredients. Black cohosh has been shown in some studies to address hot flash and night sweat symptoms, but additional studies are needed. The American College of Obstetricians and Gynecologists (ACOG) reports a concern that many of the early studies were poorly designed and did not evaluate the safety and effectiveness of black cohosh beyond 6 months of use. (13)

 In 2003 one study showed that a soy-rich diet was shown to increase the maturation indices of vaginal cells and deemed an effective preventive intervention against menopausal effects and vaginal atrophy, but more research is needed.(14)

Some products available in the market are Estroven and Remifemin.

Soy products may not be appropriate for women having breast cancer. Soy products may contain soy that has been genetically modified. My greatest concern with soy is the majority of our sources are GMO, and have advised only using non-GMO fermented soy foods such as miso or tempeh in moderation.

Here is a chart summarizing the above treatment options:

“Predominant medical therapy of vaginal dryness and pain has been with vaginal estrogen”

Predominant medical therapy of vaginal dryness and pain has been with vaginal estrogen.

This therapy can be prescribed as vaginal tablets, creams or rings.

These are delivered locally within the vagina and therefore minimize estrogen increases in blood levels along with related possible side effects.

They help improve the thickness and elasticity of the vaginal lining but do not affect the deeper tissue or supporting muscles, nor does research show that they address incontinence issues.

Anecdotal feedback from some women using these products has raised the question as to whether they help certain individuals with incontinence, but research is required to validate this question further.

Manufacturers of these prescription-only products advertise that they help with dryness, pain during intercourse and also painful urination, only.

Rather than just temporarily adding moisture (like the above lubricants) they actually work to reverse the thinning and dryness of vaginal tissue; these effects may help with painful sexual intercourse. These products have not been found to improve libido.

They are prescription-only. Examples include Vagifem, Premarin, Estring and Estrace.

Due to the estrogen content, vaginal estrogen therapy is not recommended for some women. Women with breast cancer or women with a history of stroke or heart attack, blood clots or liver disease should not opt for estrogen replacement therapies.(15) This is another reason to look at androgen hormone solutions such as DHEA versus estrogen.

Compounding hormones estrogen products, alone or in combination, that raise levels of the hormone throughout the body (systemically), not just in the vagina, are referred to as “hormone replacement therapy (HRT)”. These products address vaginal atrophy and related pain during sex in postmenopausal women as well as addressing other common symptoms of menopause such as hot flashes and night sweats.

Yes, while hot flashes can be brutal, consider them signs that self-care and detective work is needed to balance our physiology and hormones so they STOP and we feel better in all ways!  They are harbingers that we are going through some chemical ‘rewiring’ so to speak, which can actually lead us into a time of great spiritual growth… Here is an entire article dedicated to improving your hot flashes! You’ll find that there are many things you can to reduce hot flashes, including a Keto-Green® diet and lifestyle…

Estrogen products, alone or in combination with other hormones, that raise levels of the hormone throughout the body (systemically), not just in the vagina, are referred to as “hormone replacement therapy (HRT)”. These products address vaginal atrophy and related discomfort during sex in postmenopausal women as well as addressing other common symptoms of menopause such as hot flashes and night sweats.

Despite their benefits on vasomotor symptoms, 40% of women receiving systemic estrogen therapy have persistent vaginal symptoms. (16) Often local estrogen treatment is preferred unless hot flashes are the major issue. Estrogen addresses only the mucosal layer of the vaginal tissue. Research has not shown HRT to be effective in strengthening the deeper musculature of the vagina or surrounding tissue.

Studies have shown controversially that postmenopausal women do not benefit from oral hormone therapy for treatment of urinary incontinence. Some studies conclude that HRT has been associated with worsening urinary incontinence.(17)

HRT, typically not bio-identical including estrogen and progestins (differs from bio-identical progesterone) is not known to address libido although pain during sexual intercourse may be diminished.

HRT therapy has been shown to help prevent osteoporosis. (18)

Hormone replacement therapy prescriptions may contain estrogen alone or may include progestogen (synthetic progesterone) along with estrogen. There are known risks relating to increased risk of blood clots, breast cancer, heart attack and stroke with oral administration.

It is my long-term preference – from clinical and scientific experience and research – that hormone replacement should only be bio-identical and in the lowest effective dose initially to achieve optimal results.

Kegel exercises strengthen the pubococcygeus muscle and can improve symptoms of incontinence, as well as arousal and orgasm. They can also prevent or improve symptoms of pelvic organ prolapse, in which the uterus or bladder bulge into the vagina due predominantly to muscle weakness.

Kegel exercises involve contracting and relaxing the muscles of your pelvic floor, which holds your uterus and bladder above your vagina. See my video on how to do Kegel exercises correctly (many women don’t!).

You can also use Jade balls/ Lelo balls/ Kegel balls to strengthen your muscles.

It is also important to avoid exercises that cause increased pressure on the pelvic floor.

Here is a summary of the estrogen treatment options, as well as the pelvic floor health (kegels) options:

Surgical options have traditionally included specific surgeries focused on vulvar rejuvenation as well as those to support pelvic support and incontinence issues. These are currently viewed as two different categories of surgical intervention, one for functional health reasons (vaginal dryness, incontinence and prolapse) and one viewed primarily as cosmetic.

The American Society of Aesthetic Plastic Surgery (ASAPS) released statistics in 2014 that revealed a 49% increase (from 5,070 surgeries to 7.535) in labiaplasty and other genital cosmetic procedures.(19) A detailed review of these procedures can be found here. Many women view these procedures as important for their self-esteem and sexual satisfaction. However, most mainstream health organizations still consider them as cosmetic.

The American Congress of Obstetricians and Gynecologists have stated in 2007, and reaffirmed in 2014 (20) that,

“So-called “vaginal rejuvenation”, “designer vaginoplasty,” “revirgination,” and “G-spot amplification” are vaginal surgical procedures being offered by some practitioners. These procedures are not medically indicated, and the safety and effectiveness of these procedures have not been documented. Clinicians who receive requests from patients for such procedures should discuss with the patient the reason for her request and perform an evaluation for any physical signs or symptoms that may indicate the need for surgical intervention. Women should be informed about the lack of data supporting the efficacy of these procedures and their potential complications, including infection, altered sensation, dyspareunia, adhesions, and scarring.”

G-spot injection: This is the injection of collagen or Hyaluronic acid injected into the G spot. 87% of recipients in one pilot study reported increased sexual arousal and gratification.(21)

MonaLisa Touch laser therapy

This vaginal laser treatment was approved by the U.S. Food and Drug Administration (FDA) for aesthetic use in 2014, including approval for gynecologic use.(22)

The laser technology results in tissue regeneration and addresses several symptoms relating to vaginal dryness. In particular, the vaginal mucosa tissue becomes more nourished and hydrated; the epithelium becomes thicker and regains some elasticity. It also reestablishes a more acidic vaginal pH. It is not FDA approved for treating urinary incontinence. The procedure is relatively new, and is not normally covered by insurance and can be expensive.

(I've written an updated article on vaginal laser therapies if you are interested in more detailed information).

Pelvic prolapse and incontinence surgeries

Research prior to 2014 has shown that about 3% of U.S. women will have symptoms of prolapse in a given year. According to the authors of one study published in 2014, in the Journal of the American Medical Association, about 300,000 U.S. women undergo surgery for prolapse every year.(23)

The two most common surgeries are uterosacral ligament suspension and sacrospinous ligament fixation. This study, partly funded by the National Institute of Health Office of Research on Women’s Health, found positive outcomes for both treatments relating to prolapse symptoms and a small risk of side effects. The same authors suggest that by the year 2050, 44 million women in the U.S. will be facing symptoms of pelvic prolapse or pelvic floor disorders. 

While these procedures may address pelvic prolapse and incontinence issues they do not address many of the other major symptoms of vaginal atrophy including dryness and itching, pain with intercourse or libido/sexual satisfaction.

Less known hormone therapy treatment options include selective estrogen receptor modulators (SERMs) and the use of DHEA.

Women suffering from vaginal atrophy may utilize SERMs, rather than traditional estrogen therapies, for relief. SERMs block or activate the estrogen receptors in certain areas of the body and not others. This can make them safer than estrogen therapy alone especially in a woman having a history or family history of breast cancer. SERMs can also relieve other menopausal symptoms such as hot flashes and even bone density.

SERMS are unique to different parts of the body, so a SERM can block estrogen’s negative action in breast cells while activating positive effects in other cells, such as bone and uterine cells.

SERMS with positive vulvar-vaginal effects include lasofoxifene and ospemifene. These SERMs improve vaginal atrophy and reduce vaginal pH and more, but do have potentially serious side effects.(24) More research is ongoing but this is an exciting new area of addressing vaginal atrophy.

“DHEA is an androgen, like testosterone.”

While most research and available treatments have been focused on the effects of diminishing estrogen and testosterone, there is another key hormone that has been found to play an important role in addressing vaginal atrophy symptoms, and that is dehydroepiandrosterone (DHEA).

DHEA is an androgen, like testosterone. Androgens are important to the integrity of skin, muscle, and bone (in both males and females) and have a role in maintaining libido. They also improve energy level and mental alertness, provide cardiovascular protection by lowering cholesterol, and enhance bone building (by increasing calcium retention).

DHEA originates from the adrenal gland. It is an inactive precursor which leads to the production of active sex hormones like androgens or estrogens in specific cells and tissues. As estrogen levels naturally decrease it is DHEA that continues to be a remaining source of estrogens and androgens in the woman’s body.

DHEA produced by the body naturally “extends” protective benefits to women as their estrogen levels decrease, but only for a time. There is a progressive decrease in serum DHEA which starts at the age of 30 years with an average 60% loss observed by menopause.(25)

DHEA, however, can be introduced and utilized by the body.

While used for a variety of other health benefits, Oral DHEA has not been shown to address vaginal atrophy symptoms.(26)

Topical DHEA has been found to have favorable effects on skin health and appearance (27) due to the production of collagen.

If DHEA is delivered directly to the vagina, the tissues transform DHEA to the estrogen, estradiol.(28) This natural production of estradiol occurs without a significant release of estrogens systemically in the blood.

I along with other physicians have been able to write prescriptions for customized vaginal and topical DHEA and other hormones for decades with much positive results.

In November 2016 the U.S. Food and Drug Administration (FDA) approved the first product containing the active ingredient Prasterone, also known as DHEA.(29) The product, Intrarosa®, was approved to treat women experiencing moderate to severe pain during sexual intercourse, a chief symptom of vulvar atrophy.

Here’s A Summary Of Surgical, SERMS And DHEA Options

Then, I will discuss DHEA in greater detail. There is a good deal of research on the benefits of DHEA in treating vaginal atrophy symptoms.

As an Emory trained physician I started using androgen therapy in my private practice in 1999. I used bioidentical DHEA and Testosterone vaginally or applied it topically to the vulvar area.

Patients came to me complaining of vaginal atrophy symptoms including vaginal dryness, irritation, pain during intercourse and urinary leakage. Many suffered from libido issues.

Some patients also reported decreased incontinence symptoms. Many patients seeing me for possible surgery due to pelvic prolapse and stress incontinence issues were able to avoid surgery altogether once I prescribed vaginal DHEA and testosterone to them. I routinely achieved positive results with my patients for improvements to sexual health and vaginal dryness and a reduction in irritation and pain during intercourse. There were regular improvements in libido and sexual satisfaction.

For these patients, a physical examination verified their reported improvements; there were notable tissue improvements in the lining and within the vaginal ruggations (the normal folds and elasticity) as well as contractility (the ability to contract the muscles of the pelvic floor). This meant more strength, more support to the urethra and bladder too.

I wanted to be able to provide a non-prescription based topical solution that provided the least systemic effect. This would provide women all over the world with a less embarrassing option to address a significant quality of life and overall health issue associated with aging.

Three years of research along with my extensive clinical results led me to combine DHEA in cream form with other quality natural ingredients having been shown to be beneficial to the skin and its underlying tissues.

Those ingredients include Alpine Rose Stem Cells, Emu oil, Vitamin E Tocopherol, Coconut oil and Shea Butter.

Alpine Rose Stem Cells are harvested from Swiss alpine plants and contain unique compounds that help the plant survive extremely challenging environments. The stem cells have been shown in increase skin cell replenishment, protect against age-related oxidative stress, have antiviral effects and are loaded with polyphenolic antioxidant compounds.(39)

Vitamin E Tocopherol provides anti-inflammatory support; Coconut oil provides a safe and natural lubricant; Emu oil promotes deeper tissue absorption and regenerates skin cells while improving thinning skin.

My research concluded that a small 5-10 mg daily dosage of DHEA topically applied achieved excellent symptom improvements, after which I recommend a reduced maintenance dosage protocol.

You can read about my own story and why that fed into my need to research and develop Julva®, or you can learn much more about Julva® here.

Along with more information as well as testimonials, you will find an extensive FAQs on my wonderful feminine cream on the website.

The combination of the above dosage of DHEA along with the other quality natural ingredients is now available as Julva®, a restorative topical cream for the vulva, urethra, and vagina. It already has thousands of women providing heart-felt testimonials about how Julva® has helped them physically and mentally…as well as sexually.

I’ve perfected this cream with love and prayers that it helps women around the world feel good about our sexual health especially as we deal with the normal changes of age.

I’ve focused on making it really safe, and along with addressing all of the above…it is designed to effectively improve the divinely designed function of our beautiful, feminine, pelvic floor.

The remainder of this article consists of research on the positive benefits of local DHEA on vaginal atrophy symptoms, incontinence, and libido. Let’s never forget about libido, and most of the other solutions in the market do not have a direct affect on arousal and sexual satisfaction; some can help as they reduce pain (because of lubrication)…but DHEA has research specifically focused on this all important area…read on!

The research surrounding vaginally applied DHEA has shown it to:

● Reduce vaginal dryness and irritation

● Strengthen vaginal musculature

● Increase bone mineral density

● Decrease pain during intercourse

● Increase arousal and libido, as well as sexual satisfaction

In a study reported in the Journal of The North American Menopause Society in 2016 (30), daily intravaginal administration of DHEA caused highly statistically significant improvements in four measurements of vaginal atrophy.

482 Participants using DHEA (0.50% daily Prasterone for 12 weeks) resulted in:

Vaginal dryness improvements

1.44 severity score units compared to baseline, or 0.27 units over placebo

Gynecological evaluations

86% to 121% improvements (4 measures) over the placebo

Vaginal pH acidity

Decreased by 0.66 pH units over placebo

Pain during sexual activity

Decreased by 1.42 severity score units from baseline or 0.36 units over placebo

In this study and in earlier studies local Prasterone (DHEA) resulted in these improvements with minimal changes in serum steroid levels.(31) In one earlier 2009 study, 216 women were given 3 different daily doses of Prasterone, 0.25%, 0.50% and 1.0%. All three doses results in highly significant beneficial changes in vaginal secretions, a decrease in vaginal pH, epithelial surface thickness, color, and epithelial integrity.

In another 2009 study, DHEA was applied locally within the vagina resulting in a significant improvement to all three layers of the vagina (epithelium, lamina propria and muscularis) versus simply affecting the superficial epithelial cells. (32)

Strengthening this deeper musculature can help with incontinence issues (as you can also see with pelvic exercising).

I have numerous case studies demonstrating improvements in vaginal musculature as well as urinary incontinence issues through the use of locally applied DHEA.

In clinical studies, locally applied DHEA has been found to increase bone mineral density (33) and to result in an increase in serum osteocalcin, a marker of bone formation. (34)

In a clinical trial in 2015 using intravaginal Prasterone (6.5 mg daily for 12 weeks), there was a statistically significant beneficial effect on moderate to severe dyspareunia.(35) The authors also noted that vaginal dryness and dyspareunia presented together in 70-80% of women.

In the author’s 2016 study the results from the 2015 trial were confirmed. The 2016 trial included 558 postmenopausal women with moderate to severe dyspareunia as their most bothersome vaginal atrophy symptom. Results were once again statistically significant for beneficial effects at the daily intravaginal dose of 0.50% (6.5 mg) of Prasterone. (36)

In the 2009 study, 1.0% DHEA applied locally within the vagina resulted in a marked improvement to four aspects of sexual dysfunction: desire, arousal, pleasure, and orgasm. (37)

Desire showed improvements of 23% using DHEA versus placebo

Improvements in arousal and lubrication showed 139% with DHEA versus placebo

Improvements in orgasm showed 75% versus placebo

Dryness during intercourse improved 57% with DHEA versus placebo

In a 2015 study, the long-term effect on the sexual function of 154 postmenopausal women reporting some form of vaginal atrophy was evaluated based on a 52-week treatment with daily intravaginal 0.50% (6.5 mg) DHEA.

Results showed increases as follows: desire, arousal, lubrication, orgasm, satisfaction, and pain were improved by 28%, 49%, 115%, 51%, 41% and 108%, respectively. (38)

Women who have had breast cancer:

There has also been some exciting research done (in 2011, 2014 and ongoing) that has shown vaginally applied DHEA to effectively treat vaginal dryness, pain and other vaginal atrophy symptoms – including libido – especially in women having had breast cancer. See the references at the bottom if you’d like to read the individual research articles. 

Please note that after this article was written in 2017 there has been even more supportive DHEA research published, a summary of which can be found here.

Let’s start the conversation about this life-affecting problem.

So many women just deal with the symptoms by continuing to live with them, wearing panty-liners, and being unhappy and in sexual distress. Even women who are not having sexual intercourse should know there are treatments to help them live with less pain. I know many women who can’t even get a Pap Smear without great discomfort.

And we all should know how to keep our pelvic floor healthy (so as to not have to deal with prolapse issues and incontinence).