Q Having congratulated myself on sailing through the menopause with no hot flushes, I now find myself struck down with vaginal atrophy. I keep myself comfortable with Replens and vitamin E oil, vitamin pills and black cohosh. However, penetrative sex is still painful. Your articles have convinced me of the dangers of HRT, but I have had difficulty finding any information on natural and effective ways of treating this condition. - ET, Powys

A Vaginal atrophy and/or dryness is usually a consequence of a drop in oestrogen. True vaginal atrophy - where vaginal tissue deteriorates drastically - is rare. It’s more likely that what you’re experiencing is vaginal dryness, and not only menopausal women suffer this. Oestrogen production may drop while breastfeeding; douching, and yeast and other vaginal infections can also result in chronic vaginal dryness.

You are right that there has been little research into this problem as an isolated symptom. When mentioned, it‘s usually part of a catalogue of menopausal symptoms that have either improved or not with a particular drug or remedy.

After menopause as hormone levels change, the vagina can become thinner and narrower, and its natural secretions can decline. But a dry vagina is not a given in menopause. Some women have thinning of vaginal tissues but no dryness at all, while others have perfectly normal vaginal tissues, yet complain of dryness.

Although we don’t recommend reckless supplementation with phytoestrogens, this may be one case where soy phytoestrogens may be beneficial, though there are no data on which type of soy isoflavone is best for this condition. Each type has a unique impact on oestrogen-sensitive tissues, and the various types of soy may have very different effects on the lower genital tract (J Clin Endocrinol Metab, 1995; 80: 1685-90; Maturitas, 1995; 21: 189-95). You may need to experiment to find the supplement best for you.

Black cohosh has been shown to benefit a range of menopausal symptoms, including vaginal dryness. Side-effects are few, but include occasional stomach upset, but the herb’s long-term effects have not been studied. It may lower your blood pressure, so don’t take it if you’re already taking an antihypertensive.

According to some herbalists, dandelion and oat-straw tea (rich in plant oestrogens) can help restore normal vaginal lubrication.

You could also try using a simple, non-irritating, non-drying soap when washing. At night, wear a nightgown or long tee-shirt that allows air to circulate around your vagina. Avoid alcohol, caffeine and the antihistamines found in many cold remedies as all can dry the mucous membranes.

Staying sexually active to exercise the vaginal muscle is often advised, but seems to ignore the fact that a dry vagina can make sex painful. If you wish to maintain vaginal muscle tone, try integrating Kegel exercises - tightening and releasing the muscles around the vagina and anus several times in succession - into your daily routine. These exercises strengthen the pelvic floor muscles, improve sexual satisfaction and can help women of any age with urinary incontinence.

Keep you adrenals healthy since these glands continue to produce small amounts of oestrogen. High levels of both vitamin C (at least 1000 mg daily) and pantothenic acid (50-300 mg daily) may be useful in supporting adrenal function. One study showed that vitamin E supplements can produce positive changes in the blood vessels of the vagina after just one month (J Obstet Gynaecol Br Emp, 1942; 49: 482).

You may need to use a personal lubricant until you find the remedy that works for you. Some women find a water-based lubricant such as KY Jelly or Replens helps to alleviate the problems associated with vaginal dryness. Mineral oil-based products, such as petroleum jelly and baby oil, should not be used because they tend to coat the vaginal lining and inhibit your own natural secretions. Vegetable oils do not appear to cause this problem, and applying vitamin E capsules directly to the vaginal area every night for six weeks, then as and when you need it, may also prove beneficial.