What are the effects of vaginal Dehydroepiandrosterone (DHEA) on postmenopausal women?

Effects of Vaginal DHEA in Postmenopausal Women

Vaginal DHEA (prasterone) is effective for treating vaginal dryness and dyspareunia in postmenopausal women, with significant improvements in sexual desire, arousal, pain, and overall sexual function, though it should be used with caution in women with hormone-sensitive cancers. 1, 2

Mechanism and Efficacy

Vaginal DHEA works through a local action in the vagina, where it serves as a precursor for local production of both estrogens and androgens:

• Improves vaginal symptoms by:

  • Increasing vaginal lubrication (115% improvement) 3
  • Reducing dyspareunia (108% improvement) 3
  • Enhancing sexual desire (28% improvement) 3
  • Improving arousal (49% improvement) 3
  • Enhancing orgasm (51% improvement) 3
  • Increasing overall sexual satisfaction (41% improvement) 3

• Acts primarily through local mechanisms without significantly increasing systemic hormone levels 2, 3

Treatment Algorithm for Vaginal Dryness in Postmenopausal Women

1. First-line therapy: Non-hormonal options

   • Vaginal moisturizers for daily comfort
   • Lubricants during sexual activity 1, 2

2. Second-line therapy (if symptoms persist or are severe):

   • Vaginal DHEA (prasterone) daily application 1, 2
   • Vaginal estrogen (pills, rings, or creams) 2-3 times weekly 1, 2

3. For women with breast cancer history or on aromatase inhibitors:

   • Consider vaginal DHEA with caution after thorough risk-benefit discussion 1
   • Note: FDA label warns that exogenous estrogens are contraindicated in women with breast cancer history 1

Advantages of Vaginal DHEA

• Provides local hormone effects with minimal systemic absorption 2, 3
• Improves multiple aspects of sexual function beyond just vaginal symptoms 3
• May be an option for women who cannot use estrogen therapy 2
• Demonstrated safety and efficacy in an RCT of 441 breast or gynecologic cancer survivors 1

Limitations and Considerations

• Requires daily application (unlike vaginal estrogen which requires application 2-3 times weekly) 4
• Limited long-term safety data for women with hormone-sensitive cancers 1
• More expensive than some alternative treatments 2
• May not be as effective as vaginal estrogen for some women 2, 4

Adjunctive Treatments

For women with persistent symptoms or associated pelvic floor dysfunction:

• Pelvic floor physical therapy 1, 2
• Vaginal dilators for vaginismus or vaginal stenosis 1, 2
• Topical lidocaine for persistent introital pain 1
• Cognitive behavioral therapy for associated anxiety or discomfort 1

Monitoring and Follow-up

• Evaluate response to treatment after 4-6 weeks 2
• Assess for improvement in symptoms and sexual function
• Consider alternative or additional treatments if response is inadequate

Vaginal DHEA represents an important treatment option for postmenopausal women experiencing vaginal dryness and sexual dysfunction, particularly for those who cannot or prefer not to use estrogen-based therapies.