Understanding and treating intimate dryness

What is the physiology of the vulva and the vagina?

The vulva

This is the external part of your genitals. There is no such thing as a “NORMAL” vulva! The goal is to feel comfortable with your vulva. We unfairly talk about “large” and “small” lips, when we should really say outer lips and inner lips so as not to imply that “small” lips must necessarily be hidden by the “large” ones. The most important thing is that your vulva feels comfortable and is always slightly moist.

The vulva can have a slight smell, that’s thanks to pheromones! It’s a good thing! Don’t try at all costs to mask this smell. If it bothers you, talk to your midwife or doctor. Intimate hygiene soaps are mostly marketing! You can wash with whatever you like as long as you only wash the area where, in theory, there is hair. Rinse with clear water and dry gently.

At ease with your vulva, at ease in your life!

The vagina

This is a canal made up of a mucosal layer and a muscular layer, measuring on average 9.6 cm. It is able to stretch under the effect of arousal. It should always be well lubricated to feel comfortable. It houses our defence army: Lactobacilli, which make up the Döderlein flora. The secretions produced by the vaginal walls are part of the vagina’s self-cleaning system! There is therefore no need to wash the inside of the vagina during intimate washing.

A secreting vagina is a competent vagina!

The pelvic floor (perineum)

This is a large muscle that closes off the lower part of our abdomen. It is made up of several layers. It works like a trampoline: it is able to contract when it lifts and to relax when it lowers. Everyone should know about it! Yes, it helps with continence, but most of the time it should be supple and well relaxed, otherwise it can cause pain such as difficulty inserting a tampon, or pain during penetrative intercourse…

Normal vaginal secretions

• Transudation fluid: Passage of serum through the vaginal mucosa as a result of local haemodynamic changes: it’s the vagina “sweating”, a sign that it is functioning well.
• Cervical mucus: Secreted from inside the cervix, translucent, with the appearance and texture of raw egg white; the amount varies and is highest at ovulation under the influence of oestrogens; mechanical action with flow directed outwards: “plug” / “flushing” effect; chemical action: antibacterial barrier.
• Secretions have a natural acidity that explains the discolouration of underwear. Wearing panty liners all the time is not recommended.
• Be careful if the secretions become thick, white, foul-smelling, and are associated with discomfort or pain, itching, etc. In that case, you should consult a healthcare professional.
• Wash the vulva with water or with a normal or physiologic pH soap (i.e. acidic, < 5), once a day, dry gently, and don’t hesitate to apply sweet almond oil to your vulva if it feels sensitive. No need for wipes, vulvar deodorants… You should feel comfortable in your vulva. Vulvar mantra: happy vulva, silky vulva!

Happy vulva, silky vulva!

The urogenital microbiota: why is it important?

“The microbiota is a community of micro-organisms living in a given environment. The urogenital microbiota is actually made up of several microbiotas, all interconnected with one another. The vaginal microbiota, the best known, is composed mainly of lactobacilli in healthy, non-menopausal women. The urogenital microbiota also includes the urinary microbiota, the endometrial microbiota, and the perineal and vulvar microbiota. All of these are connected to the gut microbiota and interact with the microbiota of the sexual partner. In cases of recurrent urogenital conditions, a comprehensive, global approach to the patient is necessary.

A balanced urogenital microbiota is dominated by oestrogen-dependent lactobacilli. It is estimated that there are about 40% of potentially pathogenic agents within the microbiota that can multiply when its balance is disrupted. They can cause infections, vaginal dryness, dyspareunia, changes in the endometrium, as well as prematurity, miscarriages, IVF failures, and possibly cancers.

The factors that disrupt intimate comfort are numerous: courses of antibiotics, smoking, a decrease in oestrogen levels at menopause or postpartum, frequent changes of partners, diabetes, overweight, obesity, chronic stress, immunodeficiency, and not to forget poor hygiene practices…

In which situations should we think about probiotics?

In the face of any situation that creates a risk of disrupting the urogenital microbiota, specific vaginal microbiota strains should be used, mainly lactobacilli. When antibiotics are prescribed to a woman at risk of candidiasis, probiotics should be preferred over the systematic preventive prescription of antifungal ovules. Antibiotics can cause yeast infections but also bacterial vaginosis, for which antifungals are ineffective. Specific vaginal probiotics can be given orally during and for at least one week after antibiotic treatment. Recent studies have shown that Saccharomyces yeasts, well known for their effectiveness on the intestinal microbiota, can also be active at the vaginal level.

In cases of recurrent infections, daily or spaced-out probiotic intake for at least three months, with a gradual tapering off, may be recommended, provided other risk factors such as smoking, lack of physical activity, and stress are reduced or eliminated…

Probiotics are not magical. They should not be used automatically, but rather in specific, well-defined situations. Formulas combining probiotics and herbal medicine can be useful, for example in the case of frequent urinary infections, while also addressing other causes such as constipation, digestive issues, and poor or unsuitable hygiene. Hence the need for a personalised approach.

As oestrogen levels decrease during menopause, changes in the urogenital microbiota manifest as vaginal dryness and pain during intercourse… Probiotic-based preparations, taken in courses 2 to 3 times a year during perimenopause (around ages 45–47), give good results. A woman who, at the start of menopause, has sufficient vaginal lactobacilli will have 10 times less dryness and 4 times less pain than a menopausal woman without lactobacilli. Menopause can therefore be prepared for with probiotics and plant oils such as evening primrose or borage oil!

What is vaginal and vulvar dryness?

Vaginal and vulvar dryness is common, yet remains a taboo subject. It affects more than one in six women at different times in their lives. More frequent during menopause, it increases vulnerability to gynaecological infections and can disrupt sexual harmony in a couple. There are solutions to intimate dryness — make sure you respond to protect your intimate comfort!

Intimate dryness: definition

We talk about intimate dryness (vaginal dryness or vulvovaginal dryness) when the vagina or vulva is not properly hydrated. Vaginal dryness can disrupt the balance of the vaginal flora. The physical and psychological experience is far from trivial. Vaginal lubrication comes from vaginal transudate and cervical mucus depending on the cycle. Vulvar lubrication comes from “cyprine”, the fluid secreted by the Skene and Bartholin glands. It is therefore possible to suffer from vulvar dryness, vaginal dryness, or both.

Pain during intercourse is present in 85% of patients suffering from dryness, as is a reduction in sexual activity (83%). 57% of women consider that this condition has been or is the cause of serious problems in their relationship. Once again, women over 40 are more affected. Among women who do not seek treatment, more than 5% have stopped having sexual intercourse. Very common, vaginal dryness affects at some point in life 25% of women before menopause and 30% to 55% afterwards. Vaginal and vulvar dryness remains a widely taboo topic and is often hidden from doctors, gynaecologists, and midwives. This is unfortunate, as it can be treated very effectively.

Vaginal secretions come from glands located at the entrance to the vulva and from vaginal transudate. The glands secrete a slightly “sticky” fluid every day that helps clear the vagina of dead cells and other impurities or germs. Vaginal secretions make up the self-cleaning system of the uterus and vagina (dead cells, etc.). At the vulvar level, more precisely in the muscle that helps the vulva contract, the Bartholin glands produce a stringy, colourless fluid that contributes to hydrating the vagina and inner lips. Arousal and pleasure trigger vaginal lubrication in preparation for sexual intercourse.

How is intimate dryness diagnosed?

To diagnose intimate dryness, the doctor or midwife will first try to find out more about the patient by carrying out a medical interview: the symptoms described by the patient and how she feels (absence of natural lubrication, feeling of dryness, daily discomfort, rubbing from clothes, vulvar itching, etc.).

They will then perform a clinical and gynaecological examination (absence of vaginal and vulvar secretions and moisture). They may also take a vaginal swab to check the quality of the vaginal flora.

What are the symptoms and functional signs of intimate dryness?

• Burning sensations
• Irritation or local inflammation
• Vulvar itching: this is more of a vulvar symptom; it is rare to have vaginal itching. There are not many itch receptors in the vagina. If a woman feels the urge to scratch, the problem comes from the vulva. And the vulva is skin. So it can suffer from dehydration, loss of lipids, irritation caused by unsuitable soaps, or dry eczema.
• Redness of the external genital area
• Appearance of small fissures

This intimate dryness can lead to a greater susceptibility to infections and can affect a couple’s life since it may cause pain during intercourse (dyspareunia), or even a decrease in libido, and alter quality of life.

During certain periods of life, the vaginal mucosa changes and becomes more fragile. It can lose elasticity, lose its hydrating and acidifying qualities, as well as its self-cleaning capacity.

What are the contributing factors to intimate dryness?

• Hormonal causes: Menopause, hormonal changes, and pregnancy.

Then there are psychological factors, vaginal infections, stress, medical treatments, and certain contraceptive methods. Other causes also exist: smoking, alcohol, or unsuitable intimate washing can all affect lubrication.

Menopause is defined by the cessation of ovarian function, resulting in an oestrogen deficiency responsible for well-known clinical signs. For hormonal reasons, menopausal women are the most affected by vaginal and vulvar dryness. Moreover, 40% of women taking hormone replacement therapy (HRT) reportedly experience vaginal dryness.

• In cases of dryness syndrome: this occurs when the secretions of the body’s mucous membranes are not optimal. It leads to a set of symptoms: dry eyes, lack of saliva, dryness in the bronchi or skin… Vulvar dryness may also be observed.

It can sometimes be triggered by medication (oral contraceptives low in oestrogens, antidepressants, anti-allergy drugs, acne treatments, diuretics, etc.) or certain autoimmune diseases such as Sjögren’s syndrome (where antibodies attack the body’s glands).

• In cases of skin disease: lichen, eczema, and psoriasis can affect different parts of the body, including the vulva.
• Vulvodynia, which is characterised by burning sensations in the vulva leading to reflex muscle hypertonia.
• Intimate laser hair removal worsens vulvar irritation and vaginal dryness. Not only does genital area laser hair removal burn the hair bulb, but it also destroys the sebaceous glands. Yet these glands produce the hydrolipidic film that moisturises and protects the vulvar skin. On the one hand, intimate laser hair removal alters this film; on the other, it removes the little “cushion” of hair that protects the vulva from friction, which is a source of irritation.
• Any medication or substance that dries out the mouth and tongue can also dry out the vaginal mucosa, such as some antihypertensives or acne treatments (like Roaccutane).

Differential diagnosis

Herpes flare-up, eczema, psoriasis, vaginal yeast infection (note that a major difference is the presence of abundant discharge in the case of yeast infection, which is not the case with vulvar dryness).

What treatments are available for intimate dryness?

• The very first step is to talk about it. Talking will first of all help relieve some of the stress caused by this discomfort.
• If discomfort only occurs during intercourse, an intimate lubricant will be enough to bring relief — consider using a hyaluronic acid–based lubricant.
• If discomfort is present throughout the day, a simple lubricant will not be enough. It is best to make an appointment with your gynaecologist or a midwife, who can prescribe an appropriate treatment. In the meantime, or if the discomfort is manageable, regularly apply an intimate cream ( Gel Intime Hydratant Rééquilibrant) or a plant oil (sweet almond, jojoba, evening primrose, borage). These are often enriched with soothing botanicals. You can enhance their effects by getting lubricating ovules at the pharmacy, often plant-based, or evening primrose oil capsules that you can use intravaginally. Also consider intimate-area-specific probiotics, taken orally.
• Good hygiene: washing the vulva once a day in the shower is enough. It’s not recommended to use internal soaps, as they will dry out the delicate mucosa. Use a gentle cleansing solution or simply rinse with clean water, making sure to dry the area well (patting rather than rubbing vigorously!). No vaginal douches!!
• A corticosteroid-based cream in cases of eczema or psoriasis.
• An oestrogen-based cream (especially in menopausal women).
• To treat intimate dryness, you must avoid certain risk factors that can trigger it, which in most cases helps restore normal hydration levels.
• Laser therapy: some cancer treatments have a very harmful impact on the vaginal mucosa, leading to intolerable pain. For women who cannot take hormones and are not adequately relieved by other methods, there is now the option of stimulating the mucosa with vaginal laser treatment (Mona Lisa laser). Sessions are expensive (around €300 or more), but their effectiveness is remarkable when the indication is appropriate.
• Plants to soothe irritation:
  • Aloe vera, anti-inflammatory and hydrating, is found in many preparations.
  • St. John’s wort oil can be applied locally, morning and evening. “It is nourishing, healing, anti-inflammatory, pain-relieving, antibacterial, antifungal, and antiviral.”
  • Hyaluronic acid: this molecule naturally exists in the dermis and epidermis. It binds water and protects tissues from drying out. Creams and ovules containing hyaluronic acid are sufficient for mild vaginal dryness. They plump up the mucosa and restore its suppleness. “Some studies show that after a certain time, hyaluronic acid leads to re-epithelialisation of the mucosa.” In other words, simply hydrating promotes a slight regrowth of the mucosa.

BRUME INTIME APAISANTE is a mist specifically designed to refresh, hydrate, and relieve intimate discomfort while helping maintain a healthy intimate flora.

Prevention and tips

To prevent vaginal dryness, it is important to maintain good local hygiene, but not too frequent, and to avoid aggressive products. Alcohol, tobacco, and other substances should be avoided, and wearing non-irritating underwear such as cotton is recommended. You should also maintain an excellent overall lifestyle to keep stress in check. Sexual intercourse should take place after good vaginal lubrication, either natural or with the help of lubricants.

What tips can help maintain good intimate hygiene?

First of all, it’s important to know that the vagina is self-cleaning and does not need to be cleaned from the inside. Vaginal douches are therefore not recommended and, fortunately, are becoming less and less common. External washing is, however, essential and strongly influences the balance of the urogenital microbiota. The reservoir of lactobacilli, which ensure vaginal health, is located in the rectum. When vaginal lactobacilli decrease, they migrate via the perineal skin from the rectum to the vagina. If antiseptics are used daily or during infectious episodes, there is a high risk of reducing the normal vaginal colonisation, which can lead to persistent infections. Moreover, the movement of lactobacilli is assisted by the hydrolipidic film on the skin’s surface. Over-washing with water or using soaps and shower gels that are “too harsh” damages this natural hydrolipidic film and causes dryness of the mucosa.

When are we talking about inadequate hygiene?

Once a day is enough, as long as the area is rinsed and dried properly. Women who wash after every urination or bowel movement should be warned that too many washes will eventually have a harmful effect. For optimal hygiene, avoid using unsuitable products such as regular shower gels or classic soaps like Marseille soap, which are too harsh and drying. Remember that this area is specific, sensitive, and fragile. Intimate hygiene products must therefore respect both natural hydration and the local microbiota. Hydrating and lipid-rich cleansers are particularly suitable for this anatomical area. Good hygiene should be taught from an early age, so that little girls can imitate their mothers by using the same suitable products.

The author:

Article written by Camille Tallet, midwife and osteopath, specialised in gynaecological pain. She is president of the association “Périnée Bien-aimé”, which brings together healthcare professionals to raise awareness about vulvar pain and its treatments.