How to treat vaginal dryness, in six steps.

To treat vaginal dryness, stop the irritants first (douches, scented soaps, warming lubes), use a vaginal moisturizer every two to three days, and use a low osmolality lube during sex. Give arousal more time. If sex hurts, ask about pelvic floor physical therapy. If that is not enough, a clinician can discuss vaginal estrogen and other prescriptions.

Step one, stop the irritants.

Before buying anything, remove what is working against you. The vagina maintains its own moisture and its own pH, 3.8 to 4.5, and a surprising number of products strip both.

• Douches, in any form. The vagina cleans itself.
• Scented soap, body wash, feminine wash, wipes, bubble bath, bath bombs. Warm water on the outside is the whole routine.
• Warming, cooling, tingling and flavored lubes. They lean on glycols and menthol, and they are the opposite of what dry tissue needs.
• Lubes with glycerin or high osmolality. More on that in step three.
• Spermicide, if you can switch to another method.

Cleveland Clinic lists irritants among the causes of dryness, and they are the only cause you can remove this afternoon. Give it a week and see what changes.

Step two, a moisturizer on a schedule.

If you are dry every day and not just during sex, you need a product that works every day. That is a vaginal moisturizer, not a lube. It is applied every two to three days, usually at bedtime, and it binds water to the tissue between uses. The Office on Women's Health lists it as the first thing to try for menopause dryness.

Two we track with published numbers: YES VM (250 mOsm/kg, pH 4.15, iso-osmolar and pH matched) and Replens (1,200 to 2,011 mOsm/kg, pH 2.5 to 3.5, the one gynecologists name first). If your tissue is thin or easily stung, start with YES VM. The full comparison is in moisturizer vs lube.

Give it two to three weeks of consistent use before deciding whether it works. One application does nothing.

Step three, a low osmolality lube for sex.

Most people treating dryness are already using lube. The problem is which one. The two best known brands in the country measure in the thousands of mOsm/kg, and the WHO advisory on lubricants says 380 or under is ideal. A hypertonic lube pulls water out of the tissue it touches, which on already dry tissue means stinging during and more dryness after. The Edwards and Panay review in Climacteric makes the case that for atrophic tissue, lube composition is part of the treatment, not a detail.

So: a water based lube with a published osmolality under 380 and a pH near 4.5, such as Good Clean Love Almost Naked (240 to 269 mOsm/kg, pH 4.7). Or a silicone lube like Uberlube, which has no water, no osmolality, and does not evaporate. Silicone is the more forgiving choice when dryness is significant. Its one caveat is silicone toys.

Use more than you think. Reapply. Put it on both partners.

Step four, more time for arousal.

Natural lubrication is an arousal response. It needs blood flow, and blood flow needs time. Stress, exhaustion, a rushed partner and a distracted mind all shorten that window, and the result is dryness in a body that is otherwise fine. For a lot of people under fifty this is the whole cause.

The fix is not a product. It is slowing down, more time before penetration, and taking the pressure off the outcome. Lube is a bridge while that changes. A clinician or a sex therapist can help if arousal itself has become difficult, which is common and treatable.

Step five, pelvic floor physical therapy if there is pain.

Here is the step most people skip. After enough months of painful sex, the pelvic floor muscles learn to brace. The tightness then causes pain of its own, even after the dryness is handled. Pelvic floor physical therapists treat exactly this: muscle tension, trigger points, scar tissue after childbirth, and the fear response that goes with all of it.

If sex hurts, ask for a referral. You do not need to wait until everything else has failed. Our guide to lube for pelvic pain covers how lube fits into that work.

Step six, prescription options to ask about.

If you have done steps one through four for a month or two and sex still hurts, or daily dryness has not improved, that is the point to see a clinician. Moisturizers and lube manage symptoms. They do not restore thinned tissue, and after menopause that is often what is going on.

The things to ask about, by name:

• Low dose vaginal estrogen. Cream, tablet or ring, applied locally. Listed by the Office on Women's Health as an option when over the counter products are not enough.
• Vaginal DHEA (prasterone). A prescription insert.
• Ospemifene. An oral prescription for painful sex caused by atrophy.

We are naming them so you know the conversation exists, not recommending one. Which, whether, and how much depend on your history, including things like hormone sensitive cancers that only a prescriber can weigh.

What to expect, and when to go back.

Irritants out: a week to notice. Moisturizer: two to three weeks. A better lube: the first time. Pelvic floor PT: a few sessions to a few months. Prescription treatments: on the clinician's timeline.

Go back sooner if you have bleeding after sex or between periods, unusual discharge, burning when you urinate, or pain that is getting worse rather than better. Those are not dryness, and they need looking at.