The patient: Karen, a 55-year-old salon owner.

Why she came to see me: Karen had been happily married for the last 25 years and claimed her relationship’s success was due in part to the healthy sex life she and her husband shared. But in the last several months, sex had become increasingly difficult to enjoy—even painful. Years before, she’d started using coconut oil as a lubricant (and touted its benefits), but in recent months, her vaginal tissues had become tender, and she felt didn’t have as much elasticity as they once did. She feared her growing reluctance and anxiety towards intimacy would drive her sex life to a grinding halt.

How I evaluated her: I began with a comprehensive discussion about Karen’s sex life and menstruation history. Karen had experienced her last period five years earlier. Prior to menopause, her period had gotten unusually heavy, but had tapered off to light spotting before ceasing altogether. She had not taken any postmenopausal hormone-replacement therapy—largely because, she said, her menopause “was uneventful.” And while committed to regular mammograms, she had declined pelvic exams and Pap smears for the last few years, under the assumption that her lack of symptoms, combined with having the same partner for two-plus decades, rendered her safe.

Following our intake, I did a pelvic exam and a Pap. Additionally, I ordered a yeast and bacterial culture, checked her vaginal pH. I also examined her vulva by delicately touching the tissues of her labia and vaginal opening with a Q-tip to see if they were tender to light touch and pressure. When they are, this is a key sign that the tissues have begun to atrophy due to lack of hormones, particularly estrogen. The connective tissues literally break down, leaving the tissue painful to touch.

With a mirror, I showed Karen the changes I could visually detect. I also ordered a hormone test to determine her estrogen, progesterone, DHEA (dehydroepiandrosterone), and adrenal hormone levels.

What my evaluation revealed: Karen’s Pap was normal and she didn’t have vaginal yeast overgrowth or a vaginal bacterial infection. Rather, the underlying cause behind Karen’s inability to find delight in sex was discovered through the human eye in our initial consultation. Her vulvar tissues appeared thin, dry and slightly red. The area of her vulva by the opening of her vagina (known as “introitus”) looked red as well. It also looked glassy—an indicator that she had experienced some vulvar atrophy, in which the tissues in this delicate area experience a decline in elasticity and they become more fragile. This is often due to the decreased hormone levels post-menopause, as tissues of the vulva (which include the inner and outer labia, the clitoris, the clitoral hood, the urethra, and the vagina) are all estrogen-dependent. Collagen declines with diminishing hormone levels and can lead, as in Karen’s case, to vulvar-vaginal dryness and atrophy.

Her hormone test confirmed what I suspected. Karen’s levels of estrogen, progesterone, and DHEA were quite low. Her adrenal hormone level of cortisol was also waning.

How I addressed her problem: To help Karen get her sex life back on track—and to help her feel better in general—I first laid out her options for lubrication. She’d made a good choice in the past by opting for coconut oil, but the coconut oil wasn’t enough to prevent the vaginal and vulvar atrophy and didn’t provide lasting moisture. I let her know that other organic lubricants—such as Aloe Cadabra, which mimics a woman’s natural lubrication—can aid in moisturizing as well.

I also urged her to consider using hormone creams to help increase the integrity of her vulvar and vaginal tissues. One option—which I’ve suggested to other patients in my 25 years of practice—is a prescription estriol vaginal cream. Estriol is a weak estrogen—roughly 72 times weaker than the dominant estrogen called estradiol. Estriol is also the primary estrogen that supports the vulva and vagina and, due to its weakness, is considered safe for use. In addition, I recommended a very low dose of progesterone cream (there are formulations both over-the-counter and prescription) in case the estriol stimulated the lining of her uterus (the endometrium), which in rare cases may lead to a period.

Further, I suggested applying a DHEA cream (also available over-the-counter but I more often prescribe it through a compounding pharmacy) to her vulva once a day. One of the most abundant steroid hormones in the body, DHEA can convert down into testosterone—and eventually into estrogen—in a woman’s body. (I have recommended DHEA creams to other women with vulvar vaginal dryness and atrophy who don’t want to use estrogen.) According to studies, DHEA can successfully enhance the integrity of the vulvar and vaginal tissues, and allow sex to be fun and pleasurable again. What’s more, DHEA doesn’t stimulate the lining of the endometrium, and because of its ability to convert down into testosterone, it can also—bonus points!—boost libido. Indirectly, DHEA can help support cortisol levels, too.

After weighing her options, Karen decided to use all three creams: estriol, progesterone and DHEA. I ordered the cream through a compounding pharmacy and put it in a hypoallergenic VersaBase cream, and let her know that if she—like some women—could not tolerate the cream base, we could mix the hormones with cacao lotion and turn it into a suppository, or she could mix them with an oil base like olive and use them topically and internally.

I advised Karen to apply the cream in the morning after she has showered and before going to work. I explained that she should not confuse hormone creams with the lubricant that one uses when having sex. There are health risks to men who are exposed to hormones like these that they don’t need.

Important: Any use of hormones should be carefully monitored by your trusted health care provider, as we don’t know for sure that using hormones after menopause for the rest of a woman’s life is completely safe. I have all my patients using any type of hormone cream get a both a mammogram and a gynecological exam annually. If a woman is diagnosed with a hormone-related cancer, like breast or ovarian cancer, she is advised to stop using the hormone creams. If she has any post-menopausal bleeding, it needs to be further evaluated with a pelvic ultrasound to assess the uterine lining and, possibly, a uterine biopsy.

The patient’s progress: Karen responded beautifully to the treatment. The hormones not only “fluffed up” her delicate vulvar and vaginal tissues, but also gave them more integrity. She had improved vaginal lubrication, and returned to the healthy sex life she’d savored for more than half her life. The addition of hormones also made her feel more vital and grounded in general, giving her what she called “a newfound confidence.” To which I said, “Don’t you mean restored?”

To learn more, visit Dr. Laurie Steelsmith’s website, https://drsteelsmith.com, or click her to read her most recent book, Growing Younger Every Day: The Three Essential Steps for Creating Youthful Hormone Balance at Any Age.