If you’re a woman approaching menopause or you’re already there, you may have discovered a not-so-great fact about the facts of life—during this particular stage of life, sex can hurt.

Here’s why: As you transition into and through menopause, you’ll have lower levels of estrogen, the hormone that keeps the tissue of the vagina and vulva healthy and lubricated. Vaginal tissue becomes drier and thinner, which can lead to uncomfortable sex, including pain. The medical name for painful sex is dyspareunia.

Women who have it might label it with another name—killjoy.

Vaginal moisturizers, used every few days, as well as lubricants right before sex, can help. But for many women these are not enough to offset thinner, drier vaginal tissue, so there is still some discomfort or pain. In that case, the primary options that women have had from their health-care providers have been prescription vaginal inserts, including rings, or creams that contain estrogen. These are generally safe, since little of this estrogen is absorbed into the bloodstream, and there is no evidence that it increases the risk for uterine or breast cancer. But many women, especially those with a history of breast cancer, are uncomfortable with any circulating estrogen and prefer an approach that doesn’t introduce estrogen into the body.

Now they have one. It’s a new prescription product that helps you build your own estrogen back in the one place in your body where you need it most for pain-free sex.


The US Food and Drug Administration (FDA) has approved Intrarosa, a novel treatment for dyspareunia due to menopause. It comes in the form of a vaginal suppository that’s inserted once a day.

The clinical trials submitted to the FDA for approval were conducted by the manufacturer, but many other trials have also found that it’s beneficial. In one year-long study, for example, Intrarosa significantly reduced pain—and increased lubrication, orgasms and sexual satisfaction—in postmenopausal women.

What’s novel about Intrarosa, and what sets it apart from current treatments for vaginal dryness and dyspareunia, is that its active ingredient is prasterone, which most people know as a dietary supplement called dehydroepiandrosterone (DHEA).

As a vaginal insert, rather than as a dietary supplement, however, DHEA works in a novel way. It’s the raw material that vaginal cells use to produce their own estrogen. Don’t be confused by the idea that a woman in menopause is able to make her own estrogen. While it’s true that the ovaries stop producing estrogen once you’ve reached menopause, many cells in your body can still produce small amounts of the hormone used within the cells themselves. In this case, the estrogen is actually manufactured, in tiny amounts, by the vaginal tissues.

Even in menopause, the cells that line the vagina and are responsible for its health, including the ability to stay lubricated, remain richly supplied with receptor cells for estrogen (and progesterone). When small amounts of DHEA are applied topically, it stimulates these tissues to convert the DHEA and produce estrogen locally. Voila, natural lubrication, reducing friction—and pain—during sex.

Is this brand new? Not entirely. DHEA creams, both over-the-counter and prescription-only, have been available for many years. Naturopathic physicians regularly prescribe vaginal DHEA creams, for example. But FDA approval makes this approach available to women from any MD, including their primary care doctors. In truth, it’s a validation from conventional medicine of an approach that naturopaths have used for years, and that’s a good thing.

While Intrarosa is approved for women in menopause, it may be beneficial in perimenopause, when levels of estrogen fluctuate but are still declining. Your health-care provider can let you know with a test called a “maturation index evaluation,” done with a Pap smear, what your vaginal estrogen level is. If it is low, you may want to discuss whether Intrarosa is a good idea for you.


I believe that prasterone is safe, primarily because it does not affect levels of circulating estrogen at all. So there are none of the concerns, for example about increased risk for breast cancer, that come into play with increased levels of circulating estrogen.

Side effects are minor. In clinical trials, about 6% of the women who used it experienced vaginal discharge—primarily from the product itself, since it melts at body temperature. It may affect the results of a Pap smear, and while it’s not a safety concern, it’s a good idea to remind your doctor before a Pap smear that you’re using this product. For a more accurate Pap smear, stop using it three days before your test. There’s no need to monitor your hormone levels if you’re using Intrarosa.


Vaginal cells turn over rapidly, so a woman who starts using Intrarosa can expect to experience its feel-good effects fairly rapidly—in three to 10 days. After that, with daily use, there may be no need at all to apply an external lubricant to have the enjoyable, pain-free sex you want. It’s even OK to skip using Intrarosa for a day or two if you’re having a romantic long weekend and don’t want to…be disturbed.

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