What is the recommended treatment for vaginal atrophy using vaginal estrogen?

Treatment of Vaginal Atrophy Using Vaginal Estrogen

Low-dose vaginal estrogen is the most effective treatment for vaginal atrophy when non-hormonal options fail, and should be offered to women with moderate to severe symptoms who do not respond to first-line therapies. 1, 2

Stepwise Treatment Approach

First-Line: Non-Hormonal Options

• Begin with vaginal moisturizers for daily comfort and lubricants during sexual activity 3, 1
• 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 1, 2
• Topical vitamin D or E can provide additional symptom relief for vaginal dryness 2

Second-Line: Physical Therapies

• Pelvic floor physical therapy can significantly improve sexual pain, arousal, lubrication, and overall satisfaction 3, 2
• Vaginal dilators benefit women experiencing pain during sexual activity and those with vaginal stenosis 3, 1
• These interventions are particularly important for women treated with pelvic radiation therapy 3

Third-Line: Hormonal Treatments

• Low-dose vaginal estrogen is the most effective treatment when symptoms are more severe or non-hormonal options fail 3, 1
• Available formulations include:
  • Vaginal creams (estradiol, conjugated estrogens) 4, 5
  • Vaginal tablets 6
  • Vaginal rings (sustained-release) 1
• Low-dose formulations minimize systemic absorption while effectively treating symptoms 1, 7
• DHEA (prasterone) is an FDA-approved alternative for vaginal dryness and pain with sexual activity 3, 1
• Ospemifene (a selective estrogen receptor modulator) can be offered to postmenopausal women without current or history of breast cancer experiencing dyspareunia 3, 2

Special Considerations

For Women Without Cancer History

• The lowest effective dose should be used for the shortest duration consistent with treatment goals 4
• Regular follow-up evaluations every 3-6 months are recommended to determine if continued treatment is necessary 4
• Treatment persistence is higher with vaginal tablet formulations compared to creams (mean treatment duration 103.4 days for tablets versus 44.6-48.1 days for creams) 6

For Women With Breast Cancer History

• 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 3, 1
• Estriol-containing preparations may be preferable for women on aromatase inhibitors as estriol is a weaker estrogen that cannot be converted to estradiol 1, 2
• Vaginal estradiol may increase circulating estradiol in aromatase inhibitor users within 2 weeks, potentially reducing the efficacy of aromatase inhibitors 1
• DHEA (prasterone) may be offered to women with breast cancer who are on aromatase inhibitors and have not responded to previous treatments, but should be used with caution 3, 1
• Ospemifene is contraindicated in survivors with a history of estrogen-dependent cancers 2

Common Pitfalls and Caveats

• Unlike vasomotor symptoms which tend to resolve over time, atrophic vaginitis symptoms may persist indefinitely and often worsen without treatment 1
• Incomplete treatment may lead to worsening symptoms and reduced quality of life 2
• Women with an intact uterus using systemic estrogen therapy require progestogen for endometrial protection, but this is generally not needed with low-dose vaginal estrogen 4, 7
• Persistent or recurring abnormal vaginal bleeding requires appropriate diagnostic measures to rule out malignancy 4
• A large cohort study of almost 50,000 patients with breast cancer followed for up to 20 years showed no evidence of higher risk of breast cancer-specific mortality in those using vaginal estrogen 3