From the Guidelines
The first line of treatment for vaginal thinning in a postmenopausal woman is vaginal estrogen, as it is the most effective treatment for vaginal dryness leading to sexual dysfunction, and has been shown to be effective in treating itching, discomfort, and painful intercourse in postmenopausal individuals 1.
Treatment Options
When considering treatment for vaginal thinning, it's essential to weigh the benefits and risks of each option. Vaginal estrogen is a highly effective treatment, and a study in 76 postmenopausal survivors of hormone receptor (HR)–positive breast cancer receiving aromatase inhibitor (AI) therapy found that intravaginal testosterone cream or an estradiol-releasing vaginal ring were safe and improved vaginal atrophy and sexual function 1.
Safety and Efficacy
The safety of vaginal hormones has not been firmly established in survivors of estrogen-dependent cancers, but a large cohort study of almost 50,000 patients with breast cancer followed for up to 20 years showed no evidence that there was a higher risk of breast cancer–specific mortality in those using vaginal estrogen 1.
Alternative Options
Other options, such as vaginal androgens (ie, DHEA, also known as prasterone) and ospemifene, an FDA-approved selective estrogen receptor modulator (SERM), can also be considered for vaginal dryness or pain with sexual activity, but the safety data for the use of androgen-based therapy in survivors of hormonally mediated cancers are limited 1.
Recommendations
Vaginal estrogen is the recommended first-line treatment for vaginal thinning in postmenopausal women, due to its efficacy in treating vaginal dryness and improving sexual function, and its relatively safe profile, as evidenced by the lack of increased breast cancer-specific mortality in large cohort studies 1.
From the FDA Drug Label
For treatment of moderate to severe vasomotor symptoms, vulvar and vaginal atrophy associated with the menopause, the lowest dose and regimen that will control symptoms should be chosen and medication should be discontinued as promptly as possible. When prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy, topical vaginal products should be considered.
The first line of treatment for vaginal thinning in a postmenopausal woman is topical vaginal products containing estradiol, as they are specifically considered for the treatment of symptoms of vulvar and vaginal atrophy 2 2.
- The lowest effective dose should be chosen to control symptoms.
- Medication should be discontinued as promptly as possible.
- Attempts to discontinue or taper medication should be made at 3-month to 6-month intervals.
From the Research
Treatment Options for Vaginal Thinning
The first line of treatment for vaginal thinning in a postmenopausal woman includes:
- Local vaginal estrogen therapy, which has been shown to be effective and well-tolerated for treating vaginal atrophy 3
- Low-dose vaginal estrogen delivery, which is effective at the doses recommended in labeling 3
- The use of lubricants and moisturizers to alleviate symptoms such as dryness and discomfort 4, 5
Recommended Therapies
Recommended therapies for postmenopausal vulvovaginal atrophy include:
- Vaginal estrogens (estradiol, estriol, promestriene, conjugated estrogens) 5
- Androgens, although their role is limited 5
- Prasterone, a vaginal dehydroepiandrosterone 4, 5
- Laser application, although its use is not endorsed outside of clinical trials by the International Society for the Study of Vulvovaginal Disease 5
Safety of Vaginal Estrogens
The safety of vaginal estrogens has been examined in clinical trials, with results showing that low-dose vaginal estrogen preparations are effective and well-tolerated among postmenopausal women 6