Treatment of Vaginal Dryness
Start with vaginal moisturizers applied 3-5 times weekly plus water-based or silicone-based lubricants during sexual activity; if symptoms persist after 4-6 weeks, add pelvic floor physical therapy; if still inadequate, consider prescription options including vaginal DHEA or ospemifene (60 mg daily), with vaginal estrogen reserved for refractory cases. 1, 2, 3
First-Line: Non-Hormonal Topical Therapy
Vaginal moisturizers are the foundation of treatment and should be applied 3-5 times per week to the vagina, vaginal opening, and external vulvar folds for optimal symptom control, as recommended by the American College of Obstetricians and Gynecologists. 1, 3 These products provide daily maintenance of vaginal tissue health and can be as effective as low-dose estrogen for mild to moderate symptoms. 1, 2
Lubricants complement moisturizers and are specifically recommended during sexual activity:
- Water-based lubricants reduce friction and discomfort during intercourse 1, 2, 3
- Silicone-based lubricants last longer than water-based products and may provide more effective relief 1, 2
- Products should be "body-similar" with physiological pH and osmolality to avoid detrimental effects 4, 5
Additional topical options include vitamin D or E applied topically for supplementary symptom relief 1, 2, 3, and topical lidocaine applied to the vulvar vestibule before penetration for persistent introital pain. 1, 3
Second-Line: Physical and Behavioral Interventions
If symptoms persist after 4-6 weeks of first-line therapy, add these interventions:
Pelvic floor physical therapy significantly improves sexual pain, arousal, lubrication, orgasm, and overall satisfaction. 1, 2, 3 This should be considered early, particularly when pain is a prominent feature.
Vaginal dilators benefit women with vaginismus, vaginal stenosis, or pain during sexual activity, particularly those treated with pelvic radiation. 1, 2, 3 The National Comprehensive Cancer Network recommends their use for managing dyspareunia. 3
Cognitive behavioral therapy may decrease anxiety and discomfort related to sexual activity and improve overall sexual functioning. 1, 3
Third-Line: Prescription Options
When non-hormonal treatments fail after 4-6 weeks, or when symptoms are severe at presentation, consider prescription therapies:
Vaginal DHEA (Prasterone)
Vaginal DHEA is FDA-approved for vaginal dryness and dyspareunia, improving sexual desire, arousal, pain, and overall sexual function. 1, 2, 3 This is particularly useful for women on aromatase inhibitors who have not responded to non-hormonal treatments. 1, 2
Ospemifene
Ospemifene 60 mg daily is FDA-approved for moderate to severe dyspareunia and vaginal dryness in postmenopausal women. 1, 3, 6 In clinical trials, ospemifene demonstrated statistically significant improvements in dyspareunia (p=0.0012 in Trial 1, p<0.0001 in Trial 2) and vaginal dryness (p=0.0136 in Trial 1, p<0.0001 in Trial 3) compared to placebo. 6
Critical caveat: Ospemifene is contraindicated in women with current or history of breast cancer, estrogen-dependent neoplasia, active or history of DVT/PE, active or history of stroke/MI, and undiagnosed abnormal genital bleeding. 6 The FDA label carries a black box warning for increased risk of stroke (incidence rates of 1.13 and 3.39 per thousand women-years for thromboembolic and hemorrhagic stroke, respectively) and DVT (2.26 per thousand women-years). 6
Vaginal Estrogen
Vaginal estrogen is the most effective treatment when non-hormonal options fail. 2, 3 Both systemic and vaginal estrogens are effective, with evidence suggesting vaginal estrogens may be superior to systemic treatment for vaginal dryness. 7 Low-dose formulations minimize systemic absorption while effectively treating symptoms. 2
Formulations include: estradiol-releasing vaginal ring, estrogen-based vaginal creams, pessaries containing estriol, and slow-release 17β-estradiol tablets. 7
Special Considerations for Cancer Survivors
For women with hormone-positive breast cancer, non-hormonal options must be tried first before considering any hormonal therapy. 1, 2, 3
Women on aromatase inhibitors should generally avoid vaginal estrogen as it may increase circulating estradiol within 2 weeks of use and potentially reverse the efficacy of aromatase inhibitor therapy. 7, 2 Vaginal DHEA is the preferred hormonal option for these patients who haven't responded to non-hormonal treatments. 1, 2
If vaginal estrogens must be used in breast cancer survivors, estriol-containing preparations may be preferable as estriol is a weaker estrogen that cannot be converted to estradiol. 7, 2 However, a large cohort study of almost 50,000 breast cancer patients followed for up to 20 years showed no evidence of increased breast cancer-specific mortality in those using vaginal estrogen. 2
Aromatase inhibitor use is associated with significantly greater incidence of vaginal dryness compared with tamoxifen, and these symptoms may worsen with time since menopause. 7
Common Pitfalls to Avoid
Do not use ospemifene in women with breast cancer history or other contraindications listed in the FDA label. 6
Do not assume all lubricants and moisturizers are equivalent—products with unphysiological pH, osmolality, and harmful additives should be avoided. 4, 5
Do not delay pelvic floor physical therapy when pain is prominent—this intervention significantly improves multiple domains of sexual function. 1, 2, 3
Do not use vaginal estradiol preparations in women on aromatase inhibitors without careful consideration, as they may compromise cancer treatment efficacy. 7, 2