Using the DUTCH Test® for Vaginal Atrophy
by Elise Schroeder, ND
Vaginal atrophy is one of the top complaints among menopausal women and women experiencing estrogen deprivation therapy post breast cancer. Symptoms commonly include: dryness, general pain, pain with intercourse, vaginal burning, and discharge.
This condition is often paired with results that show lower estrogen and/or testosterone levels. DHEA and DHEA-metabolite levels may be within range and depend a lot on adrenal health, stress and inflammation.
Non-Hormonal Treatment Options
Sea buckthorne oil, vitamin E and coconut oil might offer some benefit to women suffering from vaginal dryness especially if they are unable to use hormonal options.
This 2014 study looked at women with vaginal dryness, itching or burning. The participants were given 3 grams of sea buckthorn oil daily. Compared to placebo, participants had improvements in vaginal health including vaginal pH, moisture and symptomatic relief1.
Women also report symptomatic relief by applying pure vitamin E oil or coconut oil, topically to soothe the dry tissues.
If the oils are not helping, locally, low-dose hormones can be incredibly helpful for symptom relief and don’t have a systemic affect.
Estrogen supports the structure and function of the urogenital area by maintaining collagen and elastic fibers. It also promotes secretions, cellular turnover, blood flow and glycogen, which affect vaginal PH. More alkaline PH increases susceptibility to infections and urinary problems.
Per this 2004 study, systemic estrogen (estradiol) replacement therapy can be used as a treatment for vaginal atrophy, but 40% of women still experience persistent vaginal dryness2. It is also contraindicated if there has been a history of hormone-mediated cancers and should be paired with progesterone to protect the uterus.
Local, or vaginal estriol (E3) treatment, improves vaginal symptoms broadly. It is generally considered safer to use in patients on estrogen deprivation therapies and does not require the use of progesterone to protect the uterine lining. It has been shown to re-vascularize the vaginal epithelium and lower urinary tract which improves lubrication, elasticity and pH and reduces vaginal dryness, irritation, itching and urinary urgency. Local estradiol (E2), like a vaginal ring or vaginal cream can also be used, but they can have systemic effects.
Testosterone also influences vaginal and urogenital tissue in general. Androgen receptors can be found in vaginal epithelium and are in greater concentration in a premenopausal woman then decline with age. Local, low-dose testosterone use improves vaginal atrophy, reduces PH, and improves symptoms including dryness and dyspareunia without increasing estradiol levels (which is especially important in breast cancer patients) plus it also helps with urinary incontinence and libido3.
DHEA is a pre-curser hormone for estrone (E1) and testosterone. It has been shown that with local low dose treatment, DHEA increases vaginal secretions, tissue color, reduces pain and increases libido. It also has been shown to stimulate the muscle layer of the vaginal wall, which estradiol has not been shown to do. Another draw to DHEA is that is does not appear to have a systemic effect, making it safe to use in women who have contraindications for estrogen or testosterone replacement4.
A little goes a long way with local hormone use. Each of the hormones discussed are often used at very low doses to relieve vaginal urogenital symptoms -- much lower than one might use to get systemic symptom relief. If the goal is to address hot flashes, night sweats, foggy thinking etc., then vaginal administration of these hormones in a larger dose is a viable option. Remember to use progesterone to protect the uterus if using estradiol in doses big enough to relieve systemic symptoms.
One might be concerned about contamination with vaginal use.
Unlike other urine-test companies, Precision Analytical has a special procedure to ensure any contamination is removed in order to ensure accurate results. DUTCH testing looks at free hormone, which is not usually found in urine. Naturally, human urine includes conjugated hormones (testosterone, estriol or estradiol), not free hormone. Levels of conjugated hormones correlate very well with systemic values of the hormone. Any free hormone found in the urine is a “contaminant” or exogenous. All samples tested are considered “contaminated”, and free hormone is always filtered out of results. You can rest assured when testing your patients who are using vaginal hormones that results are reliable and accurate.
A note from our founding scientist Mark Newman…
There is a caveat to this. We have found, rather surprisingly, that estriol can have spuriously high results even with the contamination removed. With reasonable doses of estriol, very high urine levels can be found. In these cases, we have not only removed any potentially contaminating free hormone (from the actual supplement leaching into the sample), but we have also tested for the existence of free hormone to make sure all contamination was removed. Even with this, we see some patients with very high estriol results. We have theorized that there may be some local conjugation of estriol (turning estriol into the form found in urine, estriol-glucuronide). In other situations, all estriol-glucuronide in the urine is a reflection of systemic estriol being conjugated for excretion. When estradiol and testosterone are used vaginally, the testing is very helpful. We find the testing of limited use for specifically monitoring vaginal estriol. High levels of urine estriol following vaginal estriol therapy does NOT necessarily mean too much estriol has been given.
Watch this video for more information on monitoring levels with vaginal hormones.
[1] Larmo, Yang, Hyssala, Heiko, Erkkola. Effects of sea buckthorn oil intake on vaginal atrophy in postmenopausal women: A randomized, double-blind, placebo-controlled study Maturitas Volume 79, Issue 3, November 2014 pages 316-321 2 Johnston SL, Farrell SA, Bouchard C et al. The detection and management of vaginal atrophy. J. Obstet. Gynaecol. Can. 26, 503–515 (2004). 3 Witherby S, Johnson J, Demers L et al. Topical testosterone for breast cancer patients with vaginal atrophy related to aromatase inhibitors: a phase I/II study. Oncologist 16, 424–431 (2011). 4 Labrie F, Cusan L, Gomez JL et al. Effect of intravaginal DHEA on serum DHEA and eleven of its metabolites in postmenopausal women. J. Steroid. Biochem. Mol. Biol. 111, 178–194 (2008).
