Intrarosa, The New Medication for Dyspareunia, the Sexual Symptoms of Menopause

Many women suffer moderate to severe pain during sexual intercourse after they have reached menopause. Termed dyspareunia, this condition causes recurrent pain before, during, and/or after vaginal sex. Dyspareunia may cause:

• Pain that only occurs during sexual penetration.
• Pain that occurs during any kind of penetration, even putting in a tampon.
• Deep pain during thrusting.
• Burning pain, aching pain, or throbbing pain that can last for hours after intercourse.

Dyspareunia may bring severe pain "out of nowhere," even when sex previously had been pain-free. It is not a condition that necessarily occurs with vaginismus (a spasm of the muscles surrounding the vagina), vulvodynia (chronic or constant burning or stinging pain in the vulva without a known cause), interstitial cystitis ("bladder pain syndrome" that often occurs with dribbling or urine retention), endometriosis (the appearance of tumors in the lining of the uterus that shrink and expand with a woman's menstrual cycle; during the years leading to menopause the first half of a woman's period usually gets shorter, and the tumors expand during the second half of her period, so she has more pain more often), or vulvar itching (itching caused by drying as estrogen levels lower). 

Dyspareunia isn't a simple problem. It has many causes, and there are many relatively simple interventions that can bring relief even if they don't cure the whole problem:

• Insufficient lubrication Women at any age become more "lubricated" during longer foreplay. Simply spending more time in foreplay before sex can help with vaginal pain. Women who have past menopause (or who are breastfeeding) have lower estrogen levels, which makes the problem of insufficient lubrication worse. 
• Certain medications increase vaginal dryness and vulvar itching. These include antihistamines, antidepressants, high blood pressure drugs, sedatives, and birth control pills that emphasize progestin. Women can work with their doctors to find prescription drugs that don't aggravate sexual difficulties.
• Certain illnesses usually make sex painful for women. These include endometriosis, hemorrhoids, pelvic inflammatory disease, cystitis, uterine prolapse, retroverted uterus, uterine fibroids,irritable bowel syndrome, and ovarian cysts.
• Vaginal, vulvar, or cervical trauma can make sex painful. This includes female circumcision, episiotomy (cut made in the birth canal to assist in delivering the baby), accidents, or pelvic surgery.
• Skin disorders like eczema are sometimes the problem.

Psychological factors may come into play. Pain during intercourse is almost never "all in your head," but a history of sexual abuse can contribute to pain. Most women who have dyspareunia do not have psychological issues causing the pain.

There isn't a lot that doctors can do for dyspareunia. A prescription medication called ospemifene (Osphena) can be used to deliver estrogen directly to dry tissues in the vagina. Because it is applied topically, it is much less likely to cause the kinds of undesirable side effects associated with ordinary estrogen replacement therapy.

Some women benefit from Kegel exercises or pelvic floor training that helps them control muscle tension. Others try natural remedies for dyspareunia ranging from water based lubricants and baby oil to yoga and acupuncture. One of the newest medications for the problem is actually a nutritional supplement that has been around for over 50 years.

Intrarosa for Dyspareunia, What It Is and How It Works

Intrarosa is a vaginal suppository with the active ingredient prasterone, also known as dehydroepiandrosterone or DHEA. This substance occurs naturally in the human body. In fact, it is the most abundant steroid hormone found in the human body. DHEA is the chemical from which the body makes both male and female sex hormones, both estrogen and testosterone. However, it also has hormonal potency of its own, binding to receptor sites on nerves to act as an "allosteric modulator," which can either tone down or amplify the effects of other hormones. It is responsible for the maturing of the adrenal glands during early adolescence, triggering the production of skin oils, the growth of hair, and the acquisition of adult body odor. All of these effects can occur in the female reproductive organs during use of the supplement (by mouth) or as a vaginal insert.

Intrarosa is made by the Canadian drug manufacturer Endoceutics, based in Quebec.

During clinic trials, the Endoceutics researchers found that Pap smears were different in women who had been taking the medication for 12 weeks. Before taking the medication, the cells in the vagina and cervix were smaller, less capable of making lubricating fluids, generally associated with a condition called anestrus, a lack of sexual (or more specifically reproductive) desire. After taking the medication, the cells were larger, producing more lubricating fluids, and more characteristic of the kinds of cells seen in Pap smears of sexually active women.

The women in the clinical trial who were given Intrarosa, not the placeo:

• Had lower vaginal pH, which would mean that they were less susceptible to vaginitis, urinary tract infections, and other infections of the external sex organs.
• Were less likely to report pain associated with sexual intercourse, and
• Were less likely to report vulvar itching or vaginal dryness.

Their pathology reports also showed objectively measured more vaginal lubrication, thicker vaginal membrane, fewer visible abrasions, and better color. There was just one problem with the treatment. It tended to melt at body temperature (and would presumably be more likely to melt when it is not used in Canada). The melting suppository created a vaginal discharge in about 6 percent of the women who used it. It did not cause changes in estrogen or testosterone levels that could be measured by a blood test. Its effects were limited to the linings of the organs directly involved in sexual intercourse. There is no reason to believe that using Intrarosa would increase the risk of endrometrial cancer, ovarian cancer, breast cancer, or cardiovascular disease.

Some websites report that there were no quantitative data reported to the FDA prior to approval of the drug. This isn't true. The numbers simply weren't in the press release. They were included in the published research. Those numbers show that Intrarosa doesn't work for absolutely every woman who uses it. In the clinical trials, 84 percent of women using the drug had more lubrication at the end of the twelve weeks of the clinical study. Intrarosa may not be the complete answer to the problems of painful intercourse, but for most women, it will help.