What is the recommended treatment for postmenopausal atrophic vaginitis?

From the Guidelines

The recommended treatment for postmenopausal atrophic vaginitis is low-dose vaginal estrogen therapy, as it has been shown to be the most effective treatment for vaginal dryness and has improved itching, discomfort, and painful intercourse in postmenopausal individuals 1.

Treatment Options

• First-line options include estradiol vaginal tablets (10 mcg inserted vaginally daily for 2 weeks, then twice weekly), estradiol vaginal rings (released over 3 months, replaced quarterly), or estrogen vaginal creams (0.5-1 g applied 1-3 times weekly) 1.
• Treatment should begin with daily application for 1-2 weeks, then decrease to a maintenance schedule of 1-3 times weekly.
• Non-hormonal options include regular use of vaginal moisturizers (applied every 2-3 days) and lubricants during intercourse.

Alternative Options

• For women with contraindications to estrogen therapy, such as history of breast cancer or thromboembolic disorders, ospemifene (60 mg daily oral tablet) or prasterone (6.5 mg vaginal insert nightly) may be considered 1.
• Ospemifene has been studied in several large trials of individuals with postmenopausal vulvar and vaginal atrophy and was found to effectively treat vaginal dryness and dyspareunia 1.

Important Considerations

• Vaginal androgens, such as 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.
• The panel notes that DHEA should be used with caution in survivors receiving AI therapy, because vaginal DHEA increases levels of circulating androgens, which have the potential to impact AI activity 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Use of Estradiol Vaginal Cream, 0. 01% alone or in combination with a progestin, should be limited to the shortest duration consistent with treatment goals and risks for the individual woman. Postmenopausal women should reevaluate periodically as clinically appropriate to determine if treatment is still necessary For treatment of 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 INDICATIONS AND USAGE Estradiol Vaginal Cream, 0.01% is indicated in the treatment of moderate to severe symptoms of vulvar and vaginal atrophy due to menopause.

The recommended treatment for postmenopausal atrophic vaginitis is Estradiol Vaginal Cream, 0.01%. The usual dosage range is:

• 2 to 4 g daily for one or two weeks
• Then gradually reduced to one half initial dosage for a similar period
• A maintenance dosage of 1 g, one to three times a week, may be used after restoration of the vaginal mucosa has been achieved 2. Key points to consider:
• Use the lowest dose and regimen that will control symptoms
• Limit treatment to the shortest duration consistent with treatment goals and risks for the individual woman
• Reevaluate periodically to determine if treatment is still necessary 2 2.

From the Research

Treatment Options for Postmenopausal Atrophic Vaginitis

• Local estrogen replacement therapy is a recommended treatment for postmenopausal atrophic vaginitis, as it has been shown to be effective and safe in improving symptoms 3, 4, 5.
• Different forms of local estrogen therapy, such as creams, pessaries, tablets, and the estradiol-releasing ring, are available and have been compared in terms of efficacy and safety 4.
• A study comparing vaginal estrogen cream and sustained-release estradiol vaginal tablet (Vagifem) found that both treatments were effective in improving symptoms of atrophic vaginitis, but Vagifem was reported to be more user-friendly and resulted in fewer hygienic problems 6.
• Nonhormonal over-the-counter treatments, such as vaginal moisturizers and lubricants, may provide temporary symptom relief, but hormonal treatment may be necessary for long-term management 7, 5.

Efficacy and Safety of Local Estrogen Therapy

• Local estrogen therapy has been shown to improve symptoms of atrophic vaginitis, including vaginal dryness, itching, and painful intercourse 3, 4, 6.
• The safety of local estrogen therapy has been evaluated, and it has been found to have a low risk of adverse events, including endometrial thickness and breast disorders 4.
• However, the quality of the evidence for the efficacy and safety of local estrogen therapy is generally low to moderate, due to limitations in study design and reporting 4.

Barriers to Treatment

• Despite the availability of effective treatments, many women with atrophic vaginitis may not seek medical attention due to embarrassment or concerns about safety 7.
• Healthcare professionals should initiate open and candid discussions with patients about vaginal atrophy and provide education on treatment options to address these concerns 7.