What is the recommended treatment for vaginal atrophy?

Treatment of Vaginal Atrophy

For women with symptoms of vaginal and/or vulvar atrophy, a stepwise approach should be followed, starting with non-hormonal options like lubricants and moisturizers, progressing to low-dose vaginal estrogen therapy for those who don't respond to conservative measures. 1, 2

First-Line Treatment Options

• Vaginal moisturizers and lubricants:
  • Apply moisturizers 2-3 times weekly on an ongoing basis 2
  • Use lubricants during all sexual activity to reduce friction and discomfort 2
  • Note: Moisturizers may need more frequent application (3-5 times per week) in the vagina, at the opening, and on external vulvar folds for adequate symptom relief 1

Second-Line Treatment Options (for those who don't respond to first-line therapy)

• Low-dose vaginal estrogen therapy:
  • Available forms include:
    • Estradiol-releasing vaginal ring
    • Estrogen-based vaginal creams
    • Pessaries containing estriol
    • Slow-release estradiol tablets 2, 3
  • Dosing: The FDA-approved estradiol vaginal tablets (10 mcg) have shown efficacy with minimal systemic absorption 4
  • Frequency: Daily for first 2 weeks, then twice weekly for maintenance 5
  • Monitoring: Patients should be reevaluated every 3-6 months to assess efficacy and potential risks 2, 3

Alternative Options for Women with Contraindications to Estrogen

• Vaginal DHEA (prasterone):

  • Improves sexual desire, arousal, pain, and overall sexual function 2
  • Contraindicated in women with history of breast cancer 2

• Ospemifene:

  • FDA-approved for moderate to severe dyspareunia in postmenopausal women 2
  • Contraindicated in women with known or suspected breast cancer 2

• Topical treatments:

  • Topical vitamin D or E applied locally for vaginal dryness and burning 2
  • Topical lidocaine for persistent introital pain and dyspareunia 1, 2

Non-Pharmacological Interventions

• Pelvic floor physical therapy:

  • Beneficial for patients with pelvic floor dysfunction 1, 2
  • Improves sexual pain, arousal, lubrication, and satisfaction 2

• Vaginal dilators:

  • Helpful for vaginismus and vaginal stenosis 1
  • Particularly important for women treated with pelvic radiation therapy 1
  • Should be started early for maximum benefit 1

• Cognitive behavioral therapy:

  • Useful to decrease anxiety and discomfort 1, 2
  • Can help with lower urinary tract symptoms 1

Special Considerations

For Women with Breast Cancer

• Start with non-hormonal options (moisturizers and lubricants) 2
• For women with hormone-positive breast cancer who are symptomatic and not responding to conservative measures, low-dose vaginal estrogen can be considered after thorough discussion of risks and benefits 1
• For women on aromatase inhibitors who haven't responded to previous treatments, vaginal DHEA may be offered 1

Important Precautions

• Abnormal vaginal bleeding must be evaluated before initiating vaginal estrogen therapy 2, 3
• Women with a uterus using estrogen should also receive progestin to reduce endometrial cancer risk 3
• Women with recent arterial thromboembolic disease should avoid vaginal estrogen therapy 2

Treatment Efficacy

Studies have shown that both estradiol vaginal tablets and estriol vagitories effectively treat vaginal atrophy symptoms including itching, irritation, dryness, and dyspareunia 5. The most recent evidence indicates that low-dose vaginal estriol appears safe and efficient, even for women with contraindications for steroid hormones such as those with breast cancer history 6.

Low-dose vaginal estrogen therapy has been proven effective without causing significant endometrial proliferation, making it a safe option for long-term management of vaginal atrophy 7.