From the Guidelines
Estrogen therapy is the most effective treatment for vulvovaginal atrophy (VVA), and low-dose vaginal estrogen preparations are recommended as the first-line treatment. For most women with VVA symptoms, options include vaginal creams (such as conjugated estrogens 0.5g cream or estradiol 1g cream applied daily for 1-2 weeks, then 1-3 times weekly), vaginal tablets (estradiol 10mcg tablet inserted daily for 2 weeks, then twice weekly), or vaginal rings (estradiol 2mg ring replaced every 90 days) 1.
Treatment Approach
Treatment should continue as long as symptoms persist, as VVA is typically chronic and recurs when therapy is discontinued. For women with moderate to severe symptoms who don't respond to local therapy, systemic hormone therapy may be considered. Vaginal estrogen works by restoring the vaginal epithelium, improving blood flow, increasing vaginal secretions, and normalizing vaginal pH, which collectively relieves symptoms like dryness, burning, itching, and painful intercourse.
Considerations for Estrogen-Dependent Cancers
For women with a history of estrogen-dependent cancers, consultation with an oncologist is recommended before starting estrogen therapy, and non-hormonal options like vaginal moisturizers may be considered first 1.
Alternative Options
Other treatment options, such as vaginal androgens (e.g., DHEA) and selective estrogen receptor modulators (e.g., ospemifene), may be considered for women who are not candidates for estrogen therapy or who have not responded to estrogen therapy 1.
Importance of Recent Guidelines
The most recent guidelines, such as the NCCN Guidelines Insights: Survivorship, Version 2.2024, should be consulted for the latest recommendations on the management of VVA 1.
Key Points
- Estrogen therapy is the most effective treatment for VVA
- Low-dose vaginal estrogen preparations are recommended as the first-line treatment
- Treatment should continue as long as symptoms persist
- Consultation with an oncologist is recommended for women with a history of estrogen-dependent cancers
- Non-hormonal options, such as vaginal moisturizers, may be considered for women who are not candidates for estrogen therapy.
From the FDA Drug Label
Estradiol valerate injection, USP is indicated in the: Treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with the menopause. When prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy, topical vaginal products should be considered.
Estrogen for vulvovaginal atrophy is indicated for the treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with the menopause.
- The lowest effective dose and regimen that will control symptoms should be chosen.
- Topical vaginal products should be considered when prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy 2.
- For treatment of moderate to severe vasomotor symptoms, vulvar and vaginal atrophy associated with the menopause, the usual dosage is 10 to 20 mg Estradiol valerate injection, USP every four weeks 2.
From the Research
Estrogen Treatment for Vulvovaginal Atrophy
- Estrogen treatment is recommended for vulvovaginal atrophy (VVA), a chronic condition affecting many postmenopausal women 3.
- Local estrogen therapy (LET) is the mainstay of treatment for vaginal dryness, dyspareunia, and other urogenital symptoms, and may reverse some pathophysiological mechanisms associated with decreasing endocrine function and increasing aging 4.
- Low-dose and ultra-low-dose LET is the gold standard due to its minimal systemic absorption, with circulating E2 levels persistently remaining in the postmenopausal range 4.
Efficacy and Safety of Estrogen Treatment
- A prospective study of 120 postmenopausal VVA women treated with ultra-low-dose estriol gel showed significant improvement in VVA signs and symptoms, with 93% of patients having a positive response and 75% having complete symptom and sign resolution 3.
- A systematic review and meta-analysis of 18 randomized controlled trials found that intravaginal estrogen supplementation significantly increased superficial cells, decreased parabasal cells, and reduced vaginal pH and dyspareunia in postmenopausal women 5.
- Adverse events such as vulvovaginal pruritis, mycotic infection, and urinary tract infection were reported, but the association was insignificant 5.
Treatment Options and Recommendations
- Therapeutic management of VVA should follow a sequential order, considering women's age, symptoms, general health, and treatment preference 6.
- Beneficial options include lubricants, moisturizers, vaginal estrogens (estradiol, estriol, promestriene, conjugated estrogens), androgens, prasterone, and laser application 6.
- Oral ospemifene is an effective selective estrogen receptor modulator to treat VVA, and systemic androgens have a limited role 6, 7.
- In breast cancer survivors, moisturizers and lubricants are first-line therapy, but limited absorption of low/ultra-low doses of estrogens suggests safety, especially in women under treatment with aromatase inhibitors 6, 7.