What are the recommended treatments for vaginal dryness and pain during intercourse in menopausal women?

Treatment of Vaginal Dryness and Dyspareunia in Menopausal Women

Start with non-hormonal vaginal moisturizers applied 3-5 times weekly (not the typical 2-3 times) combined with water-based lubricants during sexual activity; if symptoms persist after 4-6 weeks or are severe at presentation, escalate to low-dose vaginal estrogen therapy, which is the most effective treatment for vaginal atrophy. 1

First-Line: Non-Hormonal Approach

Daily Maintenance

• Apply vaginal moisturizers 3-5 times per week to the vagina, vaginal opening, and external vulva—not just internally 1
• Water-based, oil-based, or silicone-based moisturizers are all effective options 2
• Silicone-based products typically last longer than water-based or glycerin-based alternatives 1
• Choose products optimally balanced for osmolality and pH, physiologically similar to natural vaginal secretions 3, 4

During Sexual Activity

• Use water-based lubricants specifically during intercourse for immediate relief 2, 1
• Silicone-based lubricants are an alternative that may provide longer-lasting lubrication 1

Adjunctive Non-Hormonal Therapies

• Pelvic floor physical therapy improves sexual pain, arousal, lubrication, orgasm, and satisfaction 2, 1
• Vaginal dilators help with vaginismus, sexual aversion disorder, vaginal scarring, or stenosis from pelvic surgery/radiation 2, 1
• Topical hyaluronic acid with vitamins E and A can prevent vaginal mucosal inflammation, dryness, bleeding, and fibrosis 1

Second-Line: Low-Dose Vaginal Estrogen (Most Effective Treatment)

When to Escalate

• If symptoms do not improve after 4-6 weeks of consistent non-hormonal therapy 1
• If symptoms are severe at initial presentation 1

Available Formulations

• Vaginal estrogen creams: Apply 0.5g (containing 15 μg estradiol) once daily for 2 weeks, then twice weekly 5
• Vaginal estrogen tablets: 10 μg estradiol tablet daily for 2 weeks, then twice weekly 1
• Vaginal estrogen rings: Sustained-release formulation for continuous delivery 2, 1
• All formulations are effective for treating vaginal dryness, itching, discomfort, and dyspareunia 2

Safety Considerations

• Low-dose vaginal estrogen minimizes systemic absorption 1
• A large cohort study of nearly 50,000 breast cancer patients followed for up to 20 years showed no increased risk of breast cancer-specific mortality with vaginal estrogen use 1
• For women on aromatase inhibitors, estriol-containing preparations may be preferable as estriol is a weaker estrogen that cannot be converted to estradiol 2, 1
• Vaginal estradiol may increase circulating estradiol in aromatase inhibitor users within 2 weeks, potentially reducing AI efficacy 1

Contraindications to Vaginal Estrogen

• History of hormone-dependent cancers (relative contraindication requiring thorough risk-benefit discussion) 1
• Undiagnosed abnormal vaginal bleeding 1
• Active or recent pregnancy 1
• Active liver disease 1

Third-Line: Alternative Prescription Options

Vaginal DHEA (Prasterone)

• FDA-approved for vaginal dryness and dyspareunia in postmenopausal women 2, 1
• Improves sexual desire, arousal, pain, and overall sexual function 2, 1
• Particularly useful for women on aromatase inhibitors who have not responded to non-hormonal options 2, 1
• Applied daily (more frequent than vaginal estrogen's twice-weekly dosing) 6
• Limited safety data exists for androgen-based therapy in survivors of hormonally mediated cancers 2

Ospemifene (Oral SERM)

• FDA-approved in 2013 for moderate to severe dyspareunia in postmenopausal women 2, 1
• Effectively treats vaginal dryness and dyspareunia in large trials 2, 1
• Contraindicated in women with known, suspected, or history of breast cancer 2
• Consider only for survivors of cancers that are not hormonally sensitive 2

Intravaginal Testosterone

• A study of 76 postmenopausal breast cancer survivors on aromatase inhibitors found intravaginal testosterone cream was safe and improved vaginal atrophy and sexual function 2
• Apply to internal vaginal areas rather than externally to minimize local irritation 7

Treatment Algorithm Summary

1. Weeks 0-6: Non-hormonal moisturizers 3-5 times weekly + lubricants during sex 1
2. Week 6 assessment: If inadequate improvement, escalate to low-dose vaginal estrogen 1
3. Week 12 assessment: If vaginal estrogen ineffective or contraindicated, consider vaginal DHEA or ospemifene (if no breast cancer history) 2, 1
4. Throughout: Add pelvic floor physical therapy and/or vaginal dilators as needed 2, 1

Common Pitfalls to Avoid

• Insufficient moisturizer frequency: Many women apply only 1-2 times weekly when 3-5 times weekly is needed for adequate symptom control 1
• Internal-only application: Moisturizers must be applied to the vaginal opening and external vulva, not just inside the vagina 1
• Delayed escalation: If conservative measures fail after 4-6 weeks, escalate to vaginal estrogen rather than continuing ineffective therapy 1
• Overlooking breast cancer safety data: The large 20-year cohort study showing no increased mortality risk with vaginal estrogen should inform shared decision-making 1
• Not considering estriol for AI users: Estriol preparations are preferable for women on aromatase inhibitors as estriol cannot be converted to estradiol 2, 1

Special Populations

Breast Cancer Survivors

• Start with non-hormonal options at higher frequency (3-5 times weekly) 1
• If vaginal estrogen is needed, discuss risks and benefits thoroughly; consider estriol-containing preparations for those on aromatase inhibitors 2, 1
• Vaginal DHEA is an option for AI users who haven't responded to previous treatments 2, 1
• Small retrospective studies suggest vaginal estrogens do not adversely affect breast cancer outcomes 2, 1

Premenopausal Women with Hypoactive Sexual Desire

• Flibanserin is FDA-approved for acquired, generalized hypoactive sexual desire disorder in premenopausal women 2, 1
• Results in approximately 1 additional satisfying sexual event every 2 months 2
• Alternative options include bupropion and buspirone, though data are limited 2