First-Line Treatment for Vaginal Atrophy
The first-line treatment for vaginal atrophy consists of non-hormonal vaginal moisturizers and lubricants, including vaginal gels, oils, and topical vitamin D or E. 1
Treatment Algorithm for Vaginal Atrophy
First-Line: Non-Hormonal Options
- Regular use of vaginal moisturizers provides daily maintenance of vaginal tissue health and relieves dryness and discomfort 1, 2
- Water-based lubricants are recommended during sexual activity to reduce friction and discomfort 2
- Silicone-based lubricants may be more effective as they last longer than water-based products 2
- Topical vitamin D or E can provide additional symptom relief for vaginal dryness 1, 2
Second-Line: Physical Interventions
- Pelvic floor physical therapy can significantly improve sexual pain, arousal, lubrication, and overall satisfaction 1, 2
- Vaginal dilators benefit women experiencing pain during sexual activity and those with vaginal stenosis 1, 2
- Regular sexual activity helps maintain vaginal health 3
Third-Line: Prescription Options
- Vaginal estrogen therapy is the most effective treatment when non-hormonal options fail 1, 4
- Low-dose formulations of vaginal estrogen minimize systemic absorption while effectively treating symptoms 1, 5
- DHEA (prasterone) is FDA-approved for vaginal dryness and pain with sexual activity 1, 2
- Ospemifene, an FDA-approved selective estrogen receptor modulator (SERM), effectively treats vaginal dryness in postmenopausal women without a history of estrogen-dependent cancers 1
Clinical Considerations
Efficacy of Treatment Options
- Vaginal estrogen is superior to hyaluronic acid in relieving vaginal symptoms and improving vaginal pH, dyspareunia, and cell maturation index 6
- However, non-hormonal options should be tried first before considering hormonal treatments, especially in women with contraindications to estrogen therapy 1, 7
- Regular sexual activity should be encouraged to maintain vaginal health 3
Special Considerations for Cancer Survivors
- For breast cancer survivors, non-hormonal options should be tried first 1, 2
- Women on aromatase inhibitors should generally avoid vaginal estrogen as it may increase circulating estradiol 1
- 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
Common Pitfalls and Caveats
- Vaginal atrophy is often underdiagnosed and undertreated due to patient reluctance to discuss symptoms and provider hesitation to address the condition 7
- Unlike vasomotor symptoms which tend to resolve over time, atrophic vaginitis symptoms may persist indefinitely and often worsen without treatment 1
- Hormone-replacement therapy is no longer indicated for management of vaginal atrophy due to increased risks of breast cancer, heart attack, and stroke 8
- Ospemifene is contraindicated in survivors with a history of estrogen-dependent cancers 8
- Incomplete treatment may lead to worsening symptoms and reduced quality of life 1