What is the recommended treatment for postmenopausal women with a uterus experiencing atrophic vaginitis?

Management of Atrophic Vaginitis in Postmenopausal Women with a Uterus

For postmenopausal women with a uterus experiencing atrophic vaginitis, a stepwise approach should be followed, starting with non-hormonal options and progressing to hormonal treatments when necessary, with the addition of progestogen when using systemic estrogen therapy. 1, 2

Initial Assessment and Non-Hormonal Options

• Atrophic vaginitis affects approximately 50% of postmenopausal women and is characterized by vaginal dryness, discomfort, pruritis, dyspareunia, urinary tract infections, and urinary urgency 2
• Unlike vasomotor symptoms which tend to resolve over time, atrophic vaginitis symptoms may persist indefinitely and often worsen without treatment 2
• First-line treatment should include:
  • Vaginal moisturizers for daily comfort (applied 3-5 times weekly) 1, 2
  • Water-based or silicone-based lubricants for sexual activity 1, 2
  • Regular sexual activity to maintain vaginal health 3

Hormonal Treatment Options

• If non-hormonal options are insufficient, low-dose vaginal estrogen can be considered 1
• Important: When estrogen is prescribed for a postmenopausal woman with a uterus, progestogen should also be initiated to reduce the risk of endometrial cancer 4, 5
• A randomized clinical trial showed that women receiving conjugated estrogens without progestogen had a 64% rate of endometrial hyperplasia compared to only 6% in those receiving estrogen plus progesterone 5
• Low-dose vaginal estrogen formulations include:
  • Vaginal creams 4
  • Vaginal tablets 2
  • Vaginal rings (sustained-release) 2

Special Considerations for Women with a Uterus

• Women with an intact uterus must receive progestogen with estrogen therapy to prevent endometrial hyperplasia and cancer 4, 5, 6
• The FDA specifically states: "When estrogen is prescribed for a postmenopausal woman with a uterus, progestin should also be initiated to reduce the risk of endometrial cancer" 4
• Progesterone can be administered cyclically (typically 12 days per 28-day cycle) 5
• For vaginal symptoms specifically, some evidence suggests that combination estriol and progesterone vaginal suppositories may be effective and safe for women with atrophic vaginitis 7

Alternative Options

• For women who cannot tolerate adverse effects of progestogens, a combined formulation of estrogen and the selective estrogen receptor modulator bazedoxifene may be beneficial 6
• Ospemifene (a selective estrogen receptor modulator) may be offered to postmenopausal women experiencing dyspareunia and vaginal atrophy 1, 8
• Vaginal DHEA (prasterone) improves sexual function and may be an option for women who prefer non-estrogen treatments 2

Monitoring and Follow-up

• Patients should be reevaluated periodically (every 3-6 months) to determine if treatment is still necessary 4
• The lowest effective dose should be used for the shortest duration consistent with treatment goals 4
• Women with a uterus using estrogen should be monitored closely for signs of endometrial cancer, with appropriate diagnostic measures taken for persistent or recurring abnormal vaginal bleeding 4

Common Pitfalls to Avoid

• Failing to add progestogen when prescribing systemic estrogen to women with a uterus, which significantly increases the risk of endometrial hyperplasia and cancer 5
• Avoiding treatment altogether due to unfounded safety concerns, leading to progressive worsening of symptoms and reduced quality of life 9
• Using estrogen alone in women with a uterus, which increases endometrial cancer risk 5, 6
• Not discussing the importance of regular use of vaginal moisturizers and lubricants, which can provide significant relief even before considering hormonal options 1, 2

By following this stepwise approach and ensuring appropriate use of progestogen with estrogen therapy in women with a uterus, clinicians can effectively manage atrophic vaginitis while minimizing risks.