In my practice, I use either:
- extended-release venlafaxine, starting at a dose of 37.5 mg daily for 1 week and then increasing the dose to 75 mg once daily, or
- immediate-release venlafaxine, starting at a dose of 37.5 mg daily for 1 week followed by 37.5 mg twice daily.
- Immediate-release venlafaxine is less expensive than the extended-release formulations.
Gabapentin. Three clinical trials have reported that gabapentin at low doses, 600 mg to 900 mg daily, is effective for the treatment of hot flashes. In two clinical trials, investigators reported that gabapentin 300 mg three times daily reduced hot flashes better than placebo.7,8 In a third clinical trial, gabapentin 600 mg-prescribed as a single daily dose prior to bedtime-reduced hot flashes almost as well as low-dosage transdermal estradiol.9
Nonestrogen treatment of dry vagina
Recommend vaginal moisturizers and vaginal lubricants
There are many vaginal moisturizers available for use, including: Replens, Me Again, Vagisil Feminine Moisturizer, Feminease, and K-Y Silk-E. These moisturizers are best used at least one or more times per week. In two small studies, the vaginal moisturizer Replens was reported to be similar in effectiveness to vaginal estrogen treatment.10,11
In my practice, vaginal estrogen is superior to vaginal moisturizers for providing patients with relief from symptoms of dry vagina, but moisturizers are more effective than no treatment.
The vaginal pH levels in premenopausal and postmenopausal women are <4.5 and >5.0, respectively. A new moisturizing gel that contains lactic acid may help create a more acidic vaginal pH, which may decrease vaginal irritation, dryness, and dyspareunia more than a gel without lactic acid.12 Luvena is a "bioengineered" vaginal moisturizer and lubricant that contains ingredients to suppress the growth of anaerobic bacteria and to reduce the development of a harmful vaginal biofilm.
Many postmenopausal women with symptoms of dry vagina use a vaginal moisturizer on a regular basis and also use a lubricant prior to sexual intercourse. Many lubricants are available, including Astroglide, Slippery Stuff, K-Y Jelly, Pjur Eros, ID Millennium, and Elegance Women's Lubricant.
In my practice I have recommended hydrogenated vegetable oil as a lubricant. For example, Crisco is a hydrogenated vegetable oil that is solid at room temperature and has been reported to be an effective lubricant for vaginal dryness.
Application of a small amount of Crisco to the posterior vaginal area creates a protective and lubricated layer over the skin most susceptible to microtrauma during sexual intercourse. To make application easier, the Crisco can be removed from its container and stored in a small decorative glass jar by the bedside or in the bathroom.
My recommendation
Estrogen is typically the most effective treatment of such menopausal symptoms as sleep disorders, hot flashes, and dry vagina. However, many women prefer nonhormonal treatment of these symptoms, and for some women (such as those with estrogen-sensitive cancer) estrogen treatment is contraindicated. Three nonhormonal interventions that I have found useful in my practice are gabapentin for sleep disorders, venlafaxine for hot flashes, and Crisco as a lubricant for symptoms related to a dry vagina.