What is the recommended treatment for vulvovaginal (vaginal) atrophy in a 60-year-old female with an intact uterus using topical estrogen (estrogen replacement therapy)?

From the Guidelines

For a 60-year-old female with vulvovaginal atrophy and an intact uterus, low-dose vaginal estrogen therapy with concurrent progestin is recommended as a safe and effective treatment option, considering the potential risk of endometrial hyperplasia with unopposed estrogen use 1. Specific formulations include estradiol vaginal cream (Estrace 0.01%, apply 0.5-1g vaginally 1-3 times weekly) with concurrent oral progestin, or the estradiol vaginal ring (Estring, inserted and replaced every 90 days) with concurrent oral progestin. Treatment should begin with daily application for 1-2 weeks to achieve initial relief, then transition to a maintenance schedule. The patient should be advised that symptom improvement usually begins within 1-2 weeks but may take 4-6 weeks for maximum benefit. Treatment can be continued long-term as symptoms persist, with annual reassessment of benefits and risks. Common side effects include mild local irritation initially, which typically resolves with continued use. The estrogen works by restoring vaginal epithelial thickness, increasing blood flow, lowering vaginal pH, and improving lubrication, effectively addressing symptoms like dryness, irritation, and painful intercourse associated with vulvovaginal atrophy, as supported by recent guidelines 1. It's essential to note that while low-dose vaginal estrogen is generally considered safe, the addition of progestin is necessary for endometrial protection in women with an intact uterus, as unopposed estrogen therapy is not recommended due to the risk of endometrial hyperplasia 1. Other treatment options, such as ospemifene, may be considered for women without a history of estrogen-dependent cancers, but the evidence for its use in this population is limited 1.

Some key points to consider when treating vulvovaginal atrophy include:

• The importance of addressing sexual dysfunction and pelvic floor dysfunction simultaneously, as they often coexist 1
• The use of vaginal moisturizers and lubricants as a first-line treatment for mild symptoms 1
• The potential benefits of pelvic floor physical therapy and cognitive behavioral therapy in improving sexual function and reducing symptoms 1
• The need for ongoing assessment and monitoring of treatment effectiveness and potential side effects, particularly in women with a history of cancer or those taking hormone therapies 1

From the FDA Drug Label

When estrogen is prescribed for a postmenopausal woman with a uterus, progestin should also be initiated to reduce the risk of endometrial cancer. For women who have a uterus, adequate diagnostic measures, such as endometrial sampling, when indicated, should be undertaken to rule out malignancy in cases of undiagnosed persistent or recurring abnormal vaginal bleeding Use of estrogen, alone or in combination with a progestin, should be with the lowest effective dose and for the shortest duration consistent with treatment goals and risks for the individual woman. When prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy, topical vaginal products should be considered.

For a 60-year-old female with an intact uterus, topical estrogen is recommended for the treatment of vulvovaginal atrophy. However, if systemic estrogen is considered, it should be used with progestin to reduce the risk of endometrial cancer. The treatment should be with the lowest effective dose and for the shortest duration consistent with treatment goals and risks for the individual woman 2 2.

• Key considerations:
  • Use of estrogen with progestin in women with an intact uterus
  • Lowest effective dose and shortest duration of treatment
  • Monitoring for signs of endometrial cancer
  • Consideration of topical vaginal products for vulvovaginal atrophy treatment

From the Research

Treatment Options for Vulvovaginal Atrophy

• Topical estrogens are effective in treating vulvovaginal atrophy (VVA) and can alleviate symptoms such as vaginal dryness, irritation, and dyspareunia 3, 4.
• Low-dose vaginal estrogen therapy is considered the criterion standard for treating VVA, and is safe for most patients 4, 5.
• Non-hormonal preparations, such as lubricants and moisturizers, can be used as first-line treatment for VVA, especially in women with hormone-dependent cancers 4, 6.

Considerations for Women with Intact Uterus

• Women with an intact uterus can use topical estrogens for VVA treatment, but the safety of long-term use should be considered 4.
• The use of systemic estrogen therapy in women with an intact uterus may require additional considerations, such as the risk of endometrial hyperplasia 7.

Individualized Approach to Treatment

• An individualized approach to VVA treatment is recommended, taking into account the woman's age, symptoms, general health, and treatment preferences 4, 6.
• A variety of therapeutic options are available, including vaginal estrogens, androgens, prasterone, laser application, and pelvic floor muscle training 6.