What can be prescribed for vaginal atrophy (atrophic vaginitis)?

From the Guidelines

Vaginal estrogen is the most effective treatment for vaginal dryness leading to sexual dysfunction and should be prescribed as the first-line treatment for vaginal atrophy (atrophic vaginitis) due to its proven efficacy in treating itching, discomfort, and painful intercourse in postmenopausal individuals. Several treatment options are available for vaginal atrophy, including:

• Low-dose vaginal estrogen therapy in forms like Vagifem tablets (10 mcg estradiol, inserted twice weekly), Estring (a silicone ring containing 2 mg estradiol that lasts 90 days), or Estrace cream (0.01% estradiol, typically applied daily for 1-2 weeks then 1-3 times weekly for maintenance) 1
• Vaginal androgens (ie, DHEA, also known as prasterone) can also be considered for vaginal dryness or pain with sexual activity, although safety data for the use of androgen-based therapy in survivors of hormonally mediated cancers are limited 1
• Ospemifene (Osphena) 60 mg daily is an oral medication that can help, but its use should be considered with caution in survivors with a history of estrogen-dependent cancers 1
• Vaginal DHEA (Intrarosa) 6.5 mg daily is another option, which has been shown to be effective at reducing dyspareunia in postmenopausal individuals 1 These treatments work by improving blood flow to vaginal tissues, increasing natural lubrication, and restoring the vaginal pH and tissue elasticity. Most women notice improvement within 2-4 weeks of starting treatment. Regular use is important for continued benefit, especially with moisturizers and prescription therapies. It's worth noting that pelvic physical therapy (ie, pelvic floor muscle training) and vaginal dilators are also options for survivors with pain during sexual activity and those with vaginal stenosis from pelvic radiation, although evidence for the effectiveness of dilators is limited 1.

From the FDA Drug Label

Estradiol valerate injection, USP is indicated in the: ... Treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with the menopause. When prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy, topical vaginal products should be considered. PREMARIN therapy is indicated in the: ... Treatment of moderate to severe symptoms of vulvar and vaginal atrophy due to menopause. When prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy, topical vaginal products should be considered

Estradiol valerate injection, USP and conjugated estrogens (PREMARIN) can be prescribed for vaginal atrophy (atrophic vaginitis), but topical vaginal products should be considered when prescribing solely for this indication 2, 2, 3.

• Key points:
  • Estradiol valerate injection, USP is indicated for moderate to severe symptoms of vulvar and vaginal atrophy
  • Conjugated estrogens (PREMARIN) are also indicated for moderate to severe symptoms of vulvar and vaginal atrophy
  • Topical vaginal products should be considered for treatment of vaginal atrophy

From the Research

Treatment Options for Vaginal Atrophy

• Local estrogen therapy is considered the best and most logical treatment for urogenital atrophy, as it is safe, effective, and has few contraindications 4
• Vaginal moisturizers and lubricants can provide symptomatic relief for vaginal dryness and dyspareunia 5
• Estradiol vaginal cream 0.003% has been shown to be an effective and well-tolerated treatment for vaginal atrophy symptoms and dryness associated with menopause 6
• Other treatment options include systemic and topical hormone replacement therapy, selective estrogen receptor modulators, vaginal dehydroepiandrosterone, and non-drug therapies 7
• Vaginal DHEA has been proposed as a treatment for vaginal atrophy, but independent studies are required to confirm its efficacy and long-term safety 8

Benefits and Considerations of Treatment Options

• Local estrogen therapy has been shown to reduce vaginal dryness severity, decrease vaginal pH, and increase superficial cell percentage 6
• Vaginal moisturizers and lubricants can provide relief for vaginal dryness and dyspareunia, but may not address the underlying cause of vaginal atrophy 5
• Estradiol vaginal cream 0.003% has been shown to be effective and well-tolerated, but may require twice weekly application 6
• Vaginal DHEA may require daily dosing, which may be unpalatable for some women 8

Importance of Seeking Medical Help

• Vaginal atrophy is a common symptom of postmenopausal estrogen deficiency, but many women do not seek medical help due to embarrassment or lack of awareness 4, 7
• Healthcare providers should take an active role in inquiring about vaginal atrophic symptoms in postmenopausal women 4
• Timely diagnosis and adequate treatment can lead to restoration and maintenance of vaginal function and health 7