What is the best management approach for a 72-year-old woman with vaginal dryness and dyspareunia?

Management of Vaginal Dryness and Dyspareunia in a 72-Year-Old Woman

The best management approach for vaginal dryness and dyspareunia in a 72-year-old woman is to begin with non-hormonal treatments such as vaginal moisturizers and lubricants, followed by low-dose vaginal estrogen therapy if symptoms persist and there are no contraindications. 1, 2

First-Line Treatment: Non-Hormonal Options

• Start with regular use of vaginal moisturizers for daily maintenance of vaginal tissue health, applying them 3-5 times per week to the vagina, vaginal opening, and external vulvar folds 1, 2
• Recommend water-based lubricants specifically for sexual activity to reduce friction and discomfort 1
• Silicone-based lubricants may be more effective than water-based products as they last longer and provide extended relief 1, 2
• Consider topical vitamin D or E as additional options for symptom relief 1, 2

Second-Line Treatment: Vaginal Dilators and Physical Therapy

• Vaginal dilators can be beneficial for managing dyspareunia, especially when there is vaginal stenosis or pain with penetration 1
• Pelvic floor physical therapy should be considered to improve sexual pain, arousal, lubrication, and overall satisfaction 1, 2
• Topical anesthetics such as lidocaine can be applied to the vulvar vestibule before sexual activity to reduce pain 1

Third-Line Treatment: Prescription Options

• If non-hormonal treatments are ineffective, low-dose vaginal estrogen therapy (creams, tablets, or rings) is the most effective treatment for vaginal dryness and dyspareunia 1, 2
• Low-dose formulations minimize systemic absorption while effectively treating symptoms 2, 3
• For women with a history of 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
• Vaginal DHEA (prasterone) is an alternative for women who cannot use estrogen, improving sexual desire, arousal, pain, and overall sexual function 1, 2
• Ospemifene (a selective estrogen receptor modulator) may be offered to postmenopausal women without a history of breast cancer who experience dyspareunia 1, 2

Special Considerations

• Hormone-sensitive cancer history (especially breast cancer) requires careful consideration before using hormonal treatments 1, 2
• Women on aromatase inhibitors should generally avoid vaginal estrogen; DHEA may be a better option 1, 2
• Vaginal estrogen is contraindicated in women with undiagnosed abnormal vaginal bleeding 3
• Treatment should be at the lowest effective dose and duration, with periodic reassessment every 3-6 months 3

Complementary Approaches

• Psychoeducational support, sexual counseling, or therapy may be beneficial, especially when psychological factors contribute to sexual dysfunction 1
• Cognitive behavioral therapy can improve sexual functioning and should be considered as part of a comprehensive approach 1
• Integrative therapies such as yoga and meditation may help improve sexual function 1

Treatment Algorithm

1. Begin with non-hormonal treatments (moisturizers and lubricants)
2. If inadequate relief, add vaginal dilators and/or pelvic floor physical therapy
3. If symptoms persist, consider prescription options based on medical history:
   • No history of hormone-sensitive cancer: Low-dose vaginal estrogen
   • History of hormone-sensitive cancer: Consider DHEA or discuss risks/benefits of low-dose vaginal estrogen
4. Incorporate psychological support and counseling throughout treatment

Regular follow-up is essential to assess treatment efficacy and adjust management as needed 3.