What is the treatment for atrophic vaginitis and when is estrogen therapy indicated?

From the Guidelines

The treatment for atrophic vaginitis primarily involves vaginal moisturizers, lubricants, and estrogen therapy, with vaginal estrogen therapy being the most effective treatment for moderate to severe symptoms, as recommended by the most recent guidelines 1.

Treatment Options

• First-line treatment includes over-the-counter vaginal moisturizers (like Replens) used 2-3 times weekly and water-based lubricants during intercourse.
• For moderate to severe symptoms, vaginal estrogen therapy is recommended, with options including estradiol vaginal cream, estradiol vaginal tablets, or the estradiol vaginal ring.
• Estrogen therapy is indicated when non-hormonal options fail to provide relief or for moderate to severe symptoms affecting quality of life.

Considerations for Estrogen Therapy

• Estrogen therapy should be used with caution in women with a history of estrogen-dependent cancers, undiagnosed vaginal bleeding, or thromboembolic disorders, though local therapy has minimal systemic absorption.
• The safety of vaginal hormones has not been firmly established in survivors of estrogen-dependent cancers, and therefore, should be used with caution in this population 1.

Alternative Options

• Vaginal androgens (ie, DHEA) can also be considered for vaginal dryness or pain with sexual activity, but safety data for the use of androgen-based therapy in survivors of hormonally mediated cancers are limited 1.
• Ospemifene, an FDA-approved selective estrogen receptor modulator (SERM), has been studied in several large trials and may be considered as an option for dyspareunia in survivors without a history of estrogen-dependent cancers 1.

Ongoing Management

• Treatment should continue as long as symptoms persist, as atrophic vaginitis is typically a chronic condition requiring ongoing management.
• Pelvic floor physical therapy and cognitive behavioral therapy may also be beneficial in addressing associated pelvic floor dysfunction and improving sexual function 1.

From the FDA Drug Label

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.

The treatment for atrophic vaginitis is estrogen therapy. Estrogen therapy should be given when the symptoms of vulvar and vaginal atrophy are moderate to severe.

• The dosage and regimen of estrogen therapy should be the lowest dose that will control symptoms.
• Topical vaginal products should be considered when prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy 2.
• Patients should be started at the lowest dose for the indication and medication should be discontinued as promptly as possible 2.

From the Research

Treatment for Atrophic Vaginitis

• The treatment for atrophic vaginitis usually depends on estrogen replacement therapy, which may be provided systemically or locally 3.
• The dosage and delivery method of estrogen replacement therapy must be individualized 3.
• Vaginal moisturizers and lubricants, and participation in coitus may also be beneficial in the treatment of women with atrophic vaginitis 3.
• Nonhormonal over-the-counter treatments may provide temporary symptom relief, but the condition is progressive, and hormonal treatment may be warranted 4.
• Minimally absorbed local vaginal estrogen therapy enables administration of estrogen doses much lower than systemic doses used for vasomotor symptoms 4.
• Local therapy is also the first-line pharmacologic treatment recommended by the North American Menopause and International Menopause Societies 4.

Estrogen Therapy

• Estrogen replacement therapy may be provided systemically or locally, and the choice of therapy depends on the individual patient's needs 3, 5.
• Vaginal estrogen preparations (e.g., creams, tablets, rings) are more often recommended for women with moderate to severe atrophic vaginitis 5.
• Low doses of estrogen given orally or locally can alleviate the symptoms of atrophic vaginitis 6.
• Steady-state plasma concentrations of E2 and estrone were one-third lower after vaginal versus oral administration of conjugated estrogens 7.
• The composition of vaginal bacterial communities in women with atrophic vaginitis changes in response to hormonal therapy, with significant increases in the relative abundance of Lactobacillus spp. and decreased relative abundance of Gardnerella 6.