What are the treatment options for vaginal dryness?

Treatment Options for Vaginal Dryness

For vaginal dryness, a stepwise approach is recommended, starting with non-hormonal options like moisturizers and lubricants, progressing to physical therapy interventions, and then considering prescription treatments including vaginal estrogen therapy, DHEA, or ospemifene based on individual risk factors and symptom severity. 1, 2

First-Line: Non-Hormonal Options

• Regular use of vaginal moisturizers (applied 3-5 times weekly) provides daily maintenance of vaginal tissue health and relieves dryness and discomfort 2
• Water-based lubricants are specifically recommended during sexual activity to reduce friction and discomfort 1, 2
• Silicone-based lubricants may be more effective as they last longer than water-based products 1, 2
• Topical vitamin D or E can provide additional symptom relief for vaginal dryness 1, 2
• When selecting moisturizers and lubricants, products with pH and osmolality similar to natural vaginal secretions should be chosen for optimal comfort and safety 3, 4

Second-Line: Physical Interventions

• Pelvic floor physical therapy can significantly improve sexual pain, arousal, lubrication, and overall satisfaction 5, 1
• Vaginal dilators benefit women experiencing pain during sexual activity and those with vaginal stenosis, particularly after pelvic radiation 5, 1
• Topical anesthetics such as lidocaine can be applied to the vulvar vestibule before sexual activity to reduce pain 2
• Regular sexual activity or use of vibrators/clitoral stimulatory devices may help maintain vaginal health 5

Third-Line: Prescription Options

• Vaginal estrogen therapy (creams, tablets, rings) is the most effective treatment for vaginal dryness when non-hormonal options fail 5, 1
• Low-dose formulations of vaginal estrogen minimize systemic absorption while effectively treating symptoms 1, 6
• DHEA (prasterone) is FDA-approved for vaginal dryness and pain with sexual activity, improving sexual desire, arousal, and overall sexual function 5, 1
• Ospemifene, an FDA-approved selective estrogen receptor modulator (SERM), effectively treats vaginal dryness and dyspareunia in postmenopausal women without a history of estrogen-dependent cancers 5, 1
• Flibanserin is FDA-approved for hypoactive sexual desire disorder in premenopausal women 5, 1

Special Considerations for Cancer Survivors

• For breast cancer survivors, non-hormonal options should be tried first before considering hormonal treatments 1, 2
• Women on aromatase inhibitors should generally avoid vaginal estrogen as it may increase circulating estradiol and potentially reduce treatment efficacy 1
• DHEA may be a better option for women on aromatase inhibitors, though it should be used with caution as it increases circulating androgens 5
• Estriol-containing preparations may be preferable for women with hormone-sensitive cancers as estriol is a weaker estrogen that cannot be converted to estradiol 1
• A large cohort study of almost 50,000 breast cancer patients followed for up to 20 years showed no evidence of increased breast cancer-specific mortality in those using vaginal estrogen 5

Common Pitfalls to Avoid

• Untreated vaginal dryness typically worsens over time, unlike other menopausal symptoms which may resolve spontaneously 1, 7
• Only about 25% of women with vaginal dryness seek medical help, leading to unnecessary suffering and reduced quality of life 7
• Failure to inquire about vaginal symptoms during routine healthcare visits contributes to undertreatment 7
• Using products with unphysiological pH, high osmolality, or harmful additives can worsen symptoms and cause irritation 3, 4
• Assuming that all lubricants and moisturizers are equivalent - significant differences exist between commercial products in terms of efficacy and safety 3, 4