What are the alternative treatments for an 86-year-old woman with chronic vaginal severe inflammation who cannot tolerate vaginal estrogen (estrogen) cream?

From the Guidelines

For an 86-year-old woman with chronic vaginal severe inflammation who cannot tolerate vaginal estrogen cream, the most appropriate alternative treatment is oral ospemifene (60mg daily with food), a selective estrogen receptor modulator that can improve vaginal tissue without traditional estrogen, as recommended by the NCCN guidelines 1. This approach is based on the latest evidence from the NCCN guidelines, which suggests that ospemifene is a viable option for survivors without a history of estrogen-dependent cancers. Some key points to consider when using ospemifene include:

• It may cause hot flashes as a side effect
• It is essential to discuss the potential risks and benefits with the patient before starting treatment
• Regular follow-up appointments should be scheduled to monitor the patient's response to treatment and adjust as necessary Other alternative approaches that can be considered include:
• Vaginal moisturizers like Replens or hyaluronic acid-based products applied 2-3 times weekly
• Water-based lubricants during intimate activities for immediate symptom relief
• A short course of low-potency topical steroids like hydrocortisone 1% cream to reduce inflammation before starting other therapies
• Avoiding irritants such as scented products, douches, and harsh soaps It is crucial to note that the safety of vaginal hormones has not been firmly established in survivors of estrogen-dependent cancers, and therefore, alternative treatments like ospemifene may be a better option for some patients 1. Additionally, a study published in the Journal of Clinical Oncology suggests that clinicians may offer ospemifene to postmenopausal women without current or a history of breast cancer who are experiencing dyspareunia, vaginal atrophy, or other vaginal pain 1.

From the FDA Drug Label

The effectiveness and safety of OSPHENA on moderate to severe symptoms of vulvar and vaginal atrophy in postmenopausal women were examined in four placebo-controlled clinical trials (three 12-week efficacy trials and one 52-week long-term safety trial). In the four placebo-controlled trials, a total of 1100 women received placebo and 1416 women received 60 mg OSPHENA

For an 86-year-old woman with chronic vaginal severe inflammation who cannot tolerate vaginal estrogen (estrogen) cream, alternative treatments may include:

• Ospemifene (PO): a non-hormonal, oral medication that has been shown to be effective in reducing moderate to severe symptoms of vulvar and vaginal atrophy in postmenopausal women 2, 2, 2. It is essential to consult a healthcare provider to determine the best course of treatment for this patient.

From the Research

Alternative Treatments for Chronic Vaginal Severe Inflammation

For an 86-year-old woman who cannot tolerate vaginal estrogen cream, several alternative treatments are available:

• Nonhormonal vaginal lubricants and moisturizers, which can help alleviate symptoms of vaginal dryness and discomfort 3, 4
• Ospemifene, a selective estrogen receptor modulator (SERM) that has been approved for the treatment of moderate-to-severe dyspareunia associated with vulvovaginal atrophy (VVA) 3, 5
• Vaginal dehydroepiandrosterone, which has been shown to be effective in treating VVA symptoms 4
• Non-drug therapies, such as lifestyle modifications and pelvic floor exercises, which can help improve vaginal health and reduce symptoms of VVA 4

Benefits and Risks of Alternative Treatments

The benefits and risks of these alternative treatments include:

• Ospemifene: has been shown to be effective in improving symptoms of VVA and dyspareunia, with a low risk of side effects, including hot flushes 3, 5
• Nonhormonal vaginal lubricants and moisturizers: can provide immediate relief from vaginal dryness and discomfort, but may not address the underlying causes of VVA 3, 4
• Vaginal dehydroepiandrosterone: has been shown to be effective in treating VVA symptoms, but may have a higher risk of side effects compared to ospemifene 4

Considerations for Treatment Selection

When selecting a treatment, the following factors should be considered:

• The severity of symptoms and the impact on quality of life 3, 4
• The presence of any contraindications or precautions, such as a history of hormone-sensitive cancer 5
• The potential benefits and risks of each treatment option, including the risk of side effects and interactions with other medications 3, 5, 4