What is the treatment for atrophic vaginitis?

Treatment of Atrophic Vaginitis

The most effective treatment for atrophic vaginitis is low-dose vaginal estrogen therapy, which should be used when non-hormonal options fail to provide adequate symptom relief. 1, 2

Understanding Atrophic Vaginitis

• Atrophic vaginitis affects approximately 50% of postmenopausal women and is characterized by vaginal dryness, itching, burning, dyspareunia, and increased risk of urinary tract infections 1, 3
• Unlike vasomotor symptoms that typically resolve over time, atrophic vaginitis symptoms often persist indefinitely and worsen without treatment 1, 2
• The primary cause is decreased estrogen levels, most commonly occurring during menopause 1, 3

Treatment Algorithm

First-Line: Non-Hormonal Options

• Regular use of over-the-counter vaginal moisturizers for daily comfort (3-5 times per week) 1, 2
• Water-based lubricants during sexual activity to reduce friction and discomfort 1, 4
• Silicone-based products may provide longer-lasting lubrication than water-based options 1
• Topical application of hyaluronic acid, vitamin E, and vitamin A can help prevent vaginal mucosal inflammation and dryness 1, 5

Second-Line: Hormonal Treatments

• Low-dose vaginal estrogen therapy is the most effective treatment when non-hormonal options fail 1, 2, 6
• Available forms include:
  • Vaginal creams (estradiol) 6
  • Vaginal tablets (10 μg estradiol) 1, 5
  • Estradiol vaginal ring for sustained release 1
• DHEA (prasterone) is FDA-approved for vaginal dryness and pain with sexual activity 1, 2
• Ospemifene (a selective estrogen receptor modulator) may be offered to women without history of breast cancer who experience dyspareunia 1

Dosing Considerations

• For vaginal estrogen cream, the lowest effective dose should be used 6
• Treatment should be reevaluated periodically (every 3-6 months) 6
• Women with an intact uterus should be monitored for signs of endometrial cancer 6

Special Considerations

For Breast Cancer Patients

• Non-hormonal options should be tried first and used at higher frequency 1, 2
• If vaginal estrogen is needed, a thorough discussion of risks and benefits is essential 1, 2
• Estriol-containing preparations may be preferable for women on aromatase inhibitors as estriol is a weaker estrogen 1, 2
• DHEA (prasterone) is an option for women on aromatase inhibitors who haven't responded to previous treatments 1

Additional Therapeutic Options

• Pelvic floor exercises can help relieve vaginal pain and enhance blood flow 1
• Vaginal dilators may benefit women with vaginismus or vaginal stenosis 1
• Regular sexual activity helps maintain a healthy, functional vagina 4

Contraindications for Hormonal Treatment

• History of hormone-dependent cancers 1, 2
• Undiagnosed abnormal vaginal bleeding 1, 2
• Active liver disease 1, 2
• Recent history of thromboembolic events 2
• Pregnancy 2

Clinical Pearls and Pitfalls

• Without treatment, symptoms of atrophic vaginitis typically worsen over time 1, 2
• Treatment non-compliance may lead to worsening symptoms and reduced quality of life 1, 2
• Low-dose vaginal estrogen has minimal systemic absorption compared to oral estrogen therapy 1, 7
• Vaginal estrogen therapy has been shown to improve the vaginal microbiome by increasing Lactobacillus species, which correlates with symptom improvement 7
• The sensitive nature of the condition may prevent women from discussing symptoms with healthcare providers; direct questioning about vaginal symptoms is recommended 3