Water-Based Vaginal Moisturizers
For vaginal dryness, start with over-the-counter water-based vaginal moisturizers applied 3-5 times weekly to the vagina, vaginal opening, and external vulva, combined with water-based lubricants specifically during sexual activity. 1, 2
Recommended Water-Based Products
Daily Maintenance Moisturizers
- Replens is a well-studied non-hormonal water-based moisturizer that showed transient improvement in vaginal symptoms in breast cancer survivors 1, 3
- Apply vaginal moisturizers 3-5 times per week (not just 2-3 times as many product labels suggest) to achieve optimal symptom control 2, 4
- Application should cover the vagina, vaginal opening, and external vulvar folds—not just internally 2
Lubricants for Sexual Activity
- Water-based lubricants are recommended as first-line for use during sexual intercourse to reduce friction and discomfort 1, 4
- Silicone-based lubricants may last longer than water-based or glycerin-based products and provide extended relief 1, 2
- Both water-based and silicone-based lubricants are effective alternatives depending on personal preference 3
Product Selection Criteria
When choosing a water-based moisturizer or lubricant, select products that are:
- Physiologically similar to natural vaginal secretions in terms of pH (3.8-4.5) and osmolality 5, 6
- Free of potentially harmful additives that can cause detrimental effects due to unphysiological composition 5
- Products formulated to meet expert guidance on osmolality and pH show better tolerance and do not disrupt the vaginal microbiome 7
Alternative Non-Hormonal Options
- Hyaluronic acid-based products (combined with vitamin E and A) can help prevent vaginal mucosal inflammation, dryness, bleeding, and fibrosis 2, 8
- Topical vitamin D or E may provide additional symptom relief for vaginal dryness and discomfort 2, 4
Treatment Algorithm
Step 1: Begin with water-based moisturizers 3-5 times weekly plus water-based or silicone-based lubricants during sexual activity 1, 2
Step 2: If symptoms persist after 4-6 weeks of consistent use, reassess and consider escalating to low-dose vaginal estrogen therapy 2, 3
Step 3: For women with contraindications to estrogen (such as hormone-positive breast cancer or those on aromatase inhibitors), continue non-hormonal options at higher frequency or consider prescription alternatives like vaginal DHEA (prasterone) 2, 4
Special Considerations for Cancer Survivors
- For breast cancer survivors, non-hormonal water-based moisturizers and lubricants must be tried first before considering any hormonal options 1, 2
- Women on aromatase inhibitors should avoid hormonal therapies entirely and rely on frequent application of non-hormonal moisturizers (3-5 times weekly) 1, 2
- A large cohort study of nearly 50,000 breast cancer patients showed that even if vaginal estrogen is eventually needed, it did not increase breast cancer-specific mortality over 20 years of follow-up 3
Common Pitfalls to Avoid
- Insufficient application frequency: Many women apply moisturizers only 1-2 times weekly when 3-5 times weekly is needed for adequate symptom control 2
- Internal-only application: Moisturizers need to be applied to the vaginal opening and external vulva, not just inside the vagina 2
- Premature treatment escalation: Give non-hormonal options a full 4-6 weeks trial at proper frequency before escalating to prescription therapies 2, 3