From the Guidelines
For treating vaginal dryness after menopause, I recommend starting with over-the-counter vaginal moisturizers (like Replens or K-Y Liquibeads) used 2-3 times weekly, and water-based lubricants (such as K-Y Jelly or Astroglide) during sexual activity. If these provide insufficient relief, prescription low-dose vaginal estrogen therapy is highly effective and comes in several forms: estradiol vaginal cream (0.01%, applied 1g daily for 1-2 weeks, then 1-3 times weekly), estradiol vaginal tablets (10 mcg inserted vaginally twice weekly), or an estradiol vaginal ring (replaced every 90 days) 1. For women who cannot use estrogen, ospemifene (60mg oral tablet daily) or prasterone/DHEA vaginal inserts (6.5mg nightly for 2 weeks, then every other day) are alternatives 1. These treatments work by restoring vaginal tissue thickness, elasticity, and natural lubrication by addressing the underlying estrogen deficiency that occurs after menopause. Most vaginal estrogen preparations have minimal systemic absorption and can be used safely long-term 1. Regular application is important for maintaining results, and improvement typically begins within 2-4 weeks but may take up to 12 weeks for maximum benefit. It's essential to consider the individual patient's medical history, including any history of cancer or hormone-sensitive conditions, when selecting a treatment option 1. Pelvic floor physiotherapy and cognitive behavioral therapy may also be beneficial for patients experiencing symptoms of pelvic floor dysfunction or anxiety related to vaginal dryness 1. Ultimately, the choice of treatment should be based on a thorough discussion of the risks and benefits with the patient, taking into account their unique needs and medical history.
From the FDA Drug Label
1.2 The Treatment of Moderate to Severe Vaginal Dryness, a Symptom of Vulvar and Vaginal Atrophy, Due to Menopause. 2.2 Treatment of Moderate to Severe Vaginal Dryness, a Symptom of Vulvar and Vaginal Atrophy, Due to Menopause Take one 60 mg tablet with food once daily.
Vaginal Dryness Treatment: Ospemifene (PO) is indicated for the treatment of moderate to severe vaginal dryness, a symptom of vulvar and vaginal atrophy, due to menopause. The recommended dosage is 60 mg tablet with food once daily 2.
- Key Points:
- Ospemifene is an estrogen agonist/antagonist with tissue selective effects.
- It has agonistic effects on the endometrium.
- The treatment should be for the shortest duration consistent with treatment goals and risks for the individual woman.
- Alternative Option: Estradiol (PV) is also indicated for the treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with the menopause 3.
From the Research
Treatment Options for Vaginal Dryness Post Menopause
- Local estrogen therapy (LET) is the mainstay of treatment for vaginal dryness, dyspareunia, and other urogenital symptoms 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
- Vaginal products including different formulations (tablets, rings, capsules, pessaries, creams, gels, and ovules) and molecules (estradiol, estriol, promestriene, conjugated equine estrogens, and estrone) have been used with superimposable therapeutic results 4
- Very low-dose estradiol vaginal cream (0.003%) applied twice per week is an effective and well-tolerated treatment for vaginal dryness and other VVA symptoms 5
Safety and Efficacy of Treatment Options
- Local estrogen therapy is safe, effective, and with few contraindications 6
- Estradiol vaginal cream (0.003%) had comparable rates of treatment-emergent adverse events to placebo 5
- Low-dose vaginal estrogen therapy is the criterion standard, but caution is suggested for survivors of hormone-sensitive cancers 7
Additional Treatment Considerations
- Nonprescription treatments include vaginal lubricants, moisturizers, and dilators 7
- Pelvic floor physical therapy may be indicated for some women with concomitant pelvic floor muscle dysfunction 7
- Sex therapy may be helpful for women with sexual dysfunction 7
- Emerging treatments, such as ultra-low-dose vaginal estradiol tablets, new selective estrogen receptor modulators (SERMs), and intravaginal dehydroepiandrosterone (DHEA) are other promising options for postmenopausal women with vaginal atrophy and sexual dysfunction 8