From the Guidelines
Vaginal estrogen is the most effective treatment for vaginal dryness leading to sexual dysfunction, including dyspareunia, and is recommended as the first-line topical treatment. According to the NCCN guidelines 1, vaginal estrogen has been shown to be effective in treating itching, discomfort, and painful intercourse in postmenopausal individuals. A study in 76 postmenopausal survivors of hormone receptor (HR)–positive breast cancer receiving aromatase inhibitor (AI) therapy found that intravaginal testosterone cream or an estradiol-releasing vaginal ring were safe and improved vaginal atrophy and sexual function 1. Furthermore, a large cohort study of almost 50,000 patients with breast cancer followed for up to 20 years showed no evidence that there was a higher risk of breast cancer–specific mortality in those using vaginal estrogen 1.
Other options for treating dyspareunia include vaginal androgens (ie, DHEA, also known as prasterone) and ospemifene, an FDA-approved selective estrogen receptor modulator (SERM). However, the safety data for the use of androgen-based therapy in survivors of hormonally mediated cancers are limited 1, and ospemifene has limited data in the survivor population 1.
Key points to consider when treating dyspareunia with topical treatments include:
- Identifying the underlying cause of vaginal pain
- Using vaginal estrogen as the first-line treatment for vaginal dryness and dyspareunia
- Considering alternative options, such as vaginal androgens or ospemifene, in certain cases
- Monitoring for potential side effects and interactions with other medications, particularly in survivors of hormonally mediated cancers 1.
From the FDA Drug Label
When prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy, topical vaginal products should be considered. The FDA drug label does not answer the question.
From the Research
Topical Treatments for Vaginal Pain (Dyspareunia)
- The study 2 found that very low-dose estradiol vaginal cream (0.003%) applied twice per week is an effective and well-tolerated treatment for vulvovaginal atrophy (VVA) symptoms, including dyspareunia, in postmenopausal women.
- Another study 3 recommends an individualized approach to the management of VVA with topical estrogens and non-hormonal preparations, and suggests that topical low-dose estrogens are effective in alleviating symptoms of VVA, including dyspareunia.
- A study 4 found that an estriol-based cream (Colpogyn) is effective in the topical treatment of postmenopausal vaginal atrophy, and improves trophism of vaginal epithelium.
Non-Hormonal Preparations
- The study 3 suggests that non-hormonal preparations (lubricants and moisturizers) should be the first-line treatment for VVA in women taking adjuvant endocrine therapies for cancers considered to be hormone-dependent.
- The study 5 mentions that modern medicine has various options for treating VVA, including systemic and topical hormone replacement therapy, selective estrogen receptor modulators, vaginal dehydroepiandrosterone, lubricants, and moisturizers.
Comparison of Treatments
- The study 2 compared estradiol cream 0.003% with placebo and found that estradiol reduced vaginal dryness severity and dyspareunia at Week 8 versus placebo.
- The study 6 compared clotrimazole 1 per cent vaginal cream with miconazole nitrate 2 per cent vaginal cream for the treatment of vulvovaginal candidiasis, but this study is not directly relevant to the treatment of dyspareunia.