What are the treatment options for vaginal atrophy?

Treatment Options for Vaginal Atrophy

For women with symptoms of vaginal atrophy, a stepwise approach should be followed, starting with non-hormonal options and progressing to hormonal treatments if symptoms persist or are severe. 1

First-Line: Non-Hormonal Options

• Regular use of vaginal moisturizers can provide relief from dryness and discomfort for daily maintenance 1, 2
• Water-based lubricants are recommended for use during sexual activity to minimize dryness and pain 2
• Silicone-based lubricants may last longer than water-based or glycerin-based products for sexual activity 2
• Topical application of hyaluronic acid, along with vitamin E and A, can help prevent vaginal mucosal inflammation, dryness, bleeding, and fibrosis 1, 3

Second-Line: Hormonal Treatments

• Low-dose vaginal estrogen therapy is the most effective treatment for vaginal atrophy when non-hormonal options fail 1, 4
• Vaginal estrogen is available in several forms:
  • Creams (conjugated estrogens or estradiol) 5, 4
  • Vaginal tablets (low-dose estradiol) 6
  • Vaginal rings (sustained-release) 2
• Low-dose formulations minimize systemic absorption while effectively treating symptoms 2, 7
• Vaginal estrogens effectively reduce superficial dyspareunia and relieve urogenital symptoms related to vaginal atrophy 1, 8

Special Considerations for Cancer Patients

• For women with hormone-positive breast cancer who are symptomatic and not responding to conservative measures, low-dose vaginal estrogen can be considered after a thorough discussion of risks and benefits 1
• Estriol-containing preparations may be preferable for women on aromatase inhibitors as estriol is a weaker estrogen 2
• Vaginal dehydroepiandrosterone (DHEA/prasterone) is an option for women with breast cancer who are on aromatase inhibitors and have not responded to previous treatments 1, 2

Additional Therapeutic Options

• Pelvic floor muscle exercises help relieve vaginal pain and enhance clitoral blood flow, improving sexual function 1, 2
• Vaginal dilators may benefit women with vaginismus and/or vaginal stenosis, particularly important for women treated with pelvic radiation therapy 1
• Laser therapy (intravaginal CO2 laser) shows promise in managing vaginal atrophy, associated with increased vaginal length 1
• Ospemifene (a selective estrogen receptor modulator) may be offered to postmenopausal women without current or history of breast cancer who experience dyspareunia or vaginal atrophy 1

Treatment Persistence and Effectiveness

• Vaginal tablet formulations of estrogen show higher treatment persistence (mean 103.4 days) compared to cream formulations (44.6-48.1 days) 6
• Without treatment, symptoms of atrophic vaginitis typically worsen over time, unlike other menopausal symptoms that may resolve 2, 8
• Early identification and treatment can improve symptoms and reverse physical changes, while embedded changes may be more difficult to remedy 8

Important Considerations

• When estrogen is prescribed for a postmenopausal woman with a uterus, progestin should also be initiated to reduce the risk of endometrial cancer 4
• Use the lowest effective dose of estrogen for the shortest duration consistent with treatment goals and risks 4
• Patients should be reevaluated periodically (every 3-6 months) to determine if continued treatment is necessary 4
• For women with a uterus using estrogen therapy, adequate diagnostic measures such as endometrial sampling should be undertaken to rule out malignancy in cases of persistent or recurring abnormal vaginal bleeding 4