What is the recommended workup and treatment for atrophic vaginitis?

Workup and Treatment of Atrophic Vaginitis

For atrophic vaginitis, first-line treatment should begin with non-hormonal vaginal lubricants and moisturizers, with vaginal estrogens considered for refractory cases after careful risk assessment, particularly in patients with a history of breast cancer. 1, 2

Diagnostic Workup

History

• Assess for key symptoms:
  • Vaginal dryness
  • Dyspareunia (painful intercourse)
  • Vulvar itching or pain
  • Recurrent urinary tract infections
  • Abnormal vaginal discharge 3
• Determine menopausal status and duration since menopause 1
• Identify risk factors:
  • Use of aromatase inhibitors (significantly increases risk) 1
  • Breast cancer history 1
  • Surgical menopause 4
  • Medications with anti-estrogenic effects 4

Physical Examination

• Evaluate for:
  • Thinning of vaginal epithelium
  • Decreased vaginal lubrication
  • Signs of inflammation
  • Vaginal pH (typically elevated >5.0)
  • Rule out other causes of symptoms 4
• Take vaginal swabs if discharge is present to exclude infection 1
• If vulval pruritis is present, examine for dermatological disorders 1
• For intermittent vulvovaginal soreness, consider herpetic lesions 1

Treatment Algorithm

Step 1: Non-Hormonal Options (First-Line)

• Vaginal moisturizers and lubricants:
  • Products like Replens® or Sylk® 1
  • Apply regularly as directed, not just during intercourse
  • Less effective than topical estrogens but safer option, especially for breast cancer patients 1, 4

Step 2: For Refractory Symptoms

For Patients WITHOUT History of Breast Cancer:

• Ospemifene (60 mg daily with food):
  • Effective for dyspareunia and vaginal dryness 5, 6
  • Contraindicated in patients with:
    • Undiagnosed abnormal genital bleeding
    • Known/suspected estrogen-dependent neoplasia
    • Active DVT/PE or history of these conditions
    • Active arterial thromboembolic disease 5
  • Monitor for potential increased risk of stroke and DVT 5

For Patients WITH History of Breast Cancer:

• If non-hormonal options fail:
  • Consider vaginal estrogens with caution, particularly in patients on aromatase inhibitors 1
  • If vaginal estrogens are used:
    • Prefer estriol-containing preparations over estradiol (estriol cannot convert to estradiol) 1
    • Estriol preparations are as effective as estradiol for symptom relief 1
    • Use lowest effective dose for shortest duration 7
    • Monitor closely for adverse effects 1

Step 3: For Severe Refractory Cases

• Low-dose vaginal estrogen (if no contraindications):
  • Options include:
    • Estradiol vaginal tablets (0.025 mg, one application daily for two weeks, then twice weekly) 8
    • Estrogen-based vaginal creams
    • Estradiol-releasing vaginal ring
    • Estriol pessaries 1
  • Vaginal administration results in lower systemic absorption compared to oral administration 9
  • Use for shortest duration consistent with treatment goals 7

Special Considerations for Breast Cancer Patients

• Aromatase inhibitor users experience significantly higher incidence of vaginal dryness compared to tamoxifen users 1
• If vaginal estrogens are considered:
  • Avoid estradiol preparations in aromatase inhibitor users as they may increase circulating estradiol levels within 2 weeks 1
  • Estriol-containing preparations are preferable as they cannot convert to estradiol 1
  • Small retrospective studies suggest vaginal estrogens may not adversely affect breast cancer outcomes, but more safety data is needed 1

Monitoring and Follow-up

• Reassess after 4 weeks of treatment to evaluate symptom improvement 2
• For patients using vaginal estrogens:
  • Monitor for abnormal vaginal bleeding
  • If abnormal bleeding occurs, perform appropriate diagnostic measures including endometrial sampling when indicated 7
  • Periodically reevaluate need for continued treatment 7

Additional Measures

• For urinary frequency or recurrent UTIs, consider bladder hygiene protocols 1
• Regular sexual activity may help maintain vaginal health 4
• Address any concurrent sexual dysfunction issues, which may require multidisciplinary input 1

Remember that treatment should be tailored based on symptom severity, breast cancer history, and concurrent medications, with the goal of improving quality of life while minimizing risks.