What are the treatment options for vaginal dryness?

Treatment Options for Vaginal Dryness

Water-based lubricants and moisturizers should be the first-line treatment for vaginal dryness, with vaginal estrogen reserved for those who do not respond adequately to non-hormonal options. 1

First-Line Treatment: Non-Hormonal Options

Vaginal Moisturizers

• Apply 2-3 times weekly for ongoing relief 1
• Work by hydrating vaginal tissues and maintaining moisture between applications
• Examples include Replens and Sylk 1
• Provide longer-lasting relief than lubricants, addressing day-to-day comfort

Lubricants for Sexual Activity

• Use during all sexual activity 1
• Water-based lubricants are generally safe and effective 2
• Silicone-based products may last longer than water-based or glycerin-based products 2
• Choose products with physiological pH and osmolality to minimize irritation 1, 3

A recent randomized trial demonstrated that water-based lubricants formulated to meet WHO guidelines for osmolality and pH significantly improved sexual function and reduced pain during intercourse 3.

Second-Line Treatment: Hormonal Options

Vaginal Estrogen

• Consider for women who don't respond adequately to non-hormonal treatments 2, 1
• Effective for treating vaginal dryness, itching, discomfort, and painful intercourse 2
• Available as creams, rings, or tablets 2
• For patients with estrogen-positive breast cancer history, estriol formulations are preferred due to lower systemic absorption 1

Ospemifene (Osphena)

• Oral selective estrogen receptor modulator (SERM) approved for moderate to severe dyspareunia and vaginal dryness due to menopause 4
• Take one 60 mg tablet with food once daily 4
• Contraindicated in women with:
  • Undiagnosed abnormal genital bleeding
  • Known or suspected estrogen-dependent neoplasia
  • Active DVT, pulmonary embolism, or history of these conditions
  • Active arterial thromboembolic disease or history of these conditions 4
• Not recommended for women with breast cancer 1, 4

Treatment Algorithm Based on Patient Characteristics

For Most Women with Vaginal Dryness:

1. Start with non-hormonal moisturizers (2-3 times weekly) and lubricants during sexual activity 2, 1
2. If inadequate response after 4-8 weeks, consider vaginal estrogen therapy 2, 1

For Women with History of Estrogen-Positive Breast Cancer:

1. Non-hormonal moisturizers and lubricants are strongly preferred first-line options 1
2. If non-hormonal options fail, consider intravaginal estriol (lowest systemic absorption) only after careful discussion of risks/benefits 1
3. Avoid ospemifene due to estrogen agonist effects 4

For Women with Severe Symptoms and No Contraindications:

1. Try non-hormonal options first
2. If inadequate response, vaginal estrogen or ospemifene may be considered 4

Additional Supportive Measures

Pelvic Floor Muscle Training

• May improve sexual pain, arousal, lubrication, orgasm, and satisfaction 2
• Particularly helpful for women with concurrent pelvic floor dysfunction

Vaginal Dilators

• Consider for vaginismus, sexual aversion disorder, vaginal scarring, or vaginal stenosis 2
• Limited evidence for effectiveness but recommended in guidelines 2

Monitoring and Follow-up

• Reassess treatment effectiveness every 3-6 months 1
• For women using vaginal estrogen with intact uterus, monitor for abnormal vaginal bleeding 1
• For women on ospemifene, use for shortest duration consistent with treatment goals due to potential risks 4

Important Caveats

• Avoid products with potentially harmful ingredients that can cause irritation 5, 6
• Women should choose products that are most similar to natural vaginal secretions in terms of pH and osmolality 5, 6
• The evidence base for interventions to treat female sexual dysfunction is generally weak, highlighting the need for more high-quality studies 2
• Vaginal dryness is often underreported and undertreated despite affecting over 50% of postmenopausal women 5