What is the treatment for atrophic vaginitis?

Treatment for Atrophic Vaginitis

Start with vaginal moisturizers applied 3-5 times weekly plus 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. 1

First-Line: Non-Hormonal Treatment

Begin with non-hormonal options for all patients, particularly those with breast cancer history. 1

• Apply vaginal moisturizers 3-5 times per week (not the typical 2-3 times suggested on product labels) to the vagina, vaginal opening, and external vulva for daily maintenance 1
• Use water-based or silicone-based lubricants specifically during sexual activity for immediate relief 1
• Topical hyaluronic acid combined with vitamins E and A can help prevent vaginal mucosal inflammation, dryness, bleeding, and fibrosis 1
• Pelvic floor physical therapy improves sexual pain, arousal, lubrication, orgasm, and satisfaction 1
• Vaginal dilators help increase vaginal accommodation and identify painful areas in a non-sexual setting, particularly useful for vaginismus or vaginal stenosis 1

Reassess symptoms after 4-6 weeks of consistent non-hormonal therapy. 1

Second-Line: Low-Dose Vaginal Estrogen

If non-hormonal measures fail after 4-6 weeks or symptoms are severe, escalate to low-dose vaginal estrogen—the most effective treatment for atrophic vaginitis. 1, 2

• Vaginal estrogen tablets: 10 μg estradiol daily for 2 weeks, then twice weekly 1
• Vaginal estrogen cream: applied as directed with low-dose formulations 2
• Vaginal estrogen ring: sustained-release formulation for continuous delivery 1
• Treatment results in symptom relief in 80-90% of patients who complete therapy 1
• Low-dose formulations minimize systemic absorption 1, 2

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

Alternative Prescription Options

For women who cannot or prefer not to use vaginal estrogen, consider these FDA-approved alternatives:

• Vaginal DHEA (prasterone): FDA-approved for vaginal dryness and dyspareunia; improves sexual desire, arousal, pain, and overall sexual function 1, 2
• Ospemifene (oral SERM): FDA-approved for moderate to severe dyspareunia in postmenopausal women without breast cancer history; effectively treats vaginal dryness and dyspareunia 1
• Topical lidocaine: Can be applied to the vulvar vestibule before penetration for persistent introital pain 1

Special Considerations for Breast Cancer Patients

For women with breast cancer, non-hormonal options must be tried first at higher frequency (3-5 times per week). 1, 2

• For hormone-positive breast cancer patients not responding to conservative measures, low-dose vaginal estrogen can be considered only after thorough discussion of risks and benefits 1, 2
• Estriol-containing preparations may be preferable for women on aromatase inhibitors because 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 aromatase inhibitor efficacy 1
• Vaginal DHEA is an option for aromatase inhibitor users who haven't responded to previous treatments 1
• Small retrospective studies suggest vaginal estrogens do not adversely affect breast cancer outcomes 1

Absolute Contraindications to Hormonal Treatment

Do not use vaginal estrogen in women with: 1, 2

• History of hormone-dependent cancers (without thorough risk-benefit discussion)
• Undiagnosed abnormal vaginal bleeding
• Active or recent thromboembolic events
• Active liver disease
• Pregnancy or recent pregnancy

Critical Pitfalls to Avoid

• Insufficient moisturizer frequency: Many women apply moisturizers only 1-2 times weekly when 3-5 times weekly is needed for adequate symptom control 1
• Internal application only: Moisturizers must be applied to the vaginal opening and external vulva, not just inside the vagina 1
• Delayed treatment escalation: If conservative measures fail after 4-6 weeks, escalate to vaginal estrogen rather than continuing ineffective therapy 1
• Ignoring that symptoms worsen over time: Unlike vasomotor symptoms that resolve, atrophic vaginitis symptoms persist indefinitely and typically worsen without treatment 1, 2
• Variable absorption concerns: Vaginal estrogen absorption is variable, which raises particular concerns in patients with breast cancer history; discuss risks thoroughly 1