What are the treatment options for atrophic vaginitis?

From the Guidelines

Atrophic vaginitis is best treated with vaginal estrogen therapy, which directly addresses the underlying cause of thinning vaginal tissues due to estrogen deficiency. First-line treatments include vaginal estrogen preparations such as estradiol vaginal cream (0.01%, applied 1g daily for 1-2 weeks, then 1-3 times weekly), estradiol vaginal tablets (10 mcg inserted vaginally daily for 2 weeks, then twice weekly), or an estradiol vaginal ring (2 mg, replaced every 90 days) 1. For women who cannot or prefer not to use hormonal treatments, regular use of vaginal moisturizers (applied 2-3 times weekly) and lubricants during intercourse can provide symptomatic relief. Severe cases may benefit from systemic hormone therapy if there are no contraindications. Treatment should be continued long-term as symptoms typically recur when therapy is discontinued. These treatments work by restoring the thickness and elasticity of vaginal tissues, normalizing vaginal pH, and improving blood flow to the area, which reduces symptoms like dryness, burning, itching, and pain during intercourse. Patients should expect improvement within 2-4 weeks of starting treatment, though complete resolution may take 1-3 months.

Key Considerations

• Vaginal estrogen is the most effective treatment for vaginal dryness leading to sexual dysfunction and has been shown to be effective in treating itching, discomfort, and painful intercourse in postmenopausal individuals 1.
• A large cohort study of almost 50,000 patients with breast cancer followed for up to 20 years showed no evidence that there was a higher risk of breast cancer–specific mortality in those using vaginal estrogen 1.
• Vaginal androgens (ie, DHEA, also known as prasterone) can also be considered for vaginal dryness or pain with sexual activity, but safety data for the use of androgen-based therapy in survivors of hormonally mediated cancers are limited 1.
• Ospemifene, an FDA-approved selective estrogen receptor modulator (SERM), has been studied in several large trials of individuals with postmenopausal vulvar and vaginal atrophy and was found to effectively treat vaginal dryness and dyspareunia, but data in the survivor population are very limited 1.

Alternative Options

• Vaginal moisturizers and lubricants can provide symptomatic relief for women who cannot or prefer not to use hormonal treatments 1.
• Pelvic floor physiotherapy may be beneficial for patients experiencing symptoms of a potential pelvic floor dysfunction, including persistent pain and urinary and/or fecal leakage 1.
• Cognitive behavioral therapy and pelvic floor (Kegel) exercises may be useful to decrease anxiety and discomfort and can lower urinary tract symptoms 1.

From the FDA Drug Label

When prescribing solely for the treatment of moderate to severe vaginal dryness and pain during intercourse, topical vaginal products should be considered. The treatment of moderate to severe vaginal dryness and pain with intercourse, symptoms of vulvar and vaginal atrophy, associated with menopause. Treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with the menopause. For treatment of moderate to severe vasomotor symptoms, vulvar and vaginal atrophy associated with the menopause, the lowest dose and regimen that will control symptoms should be chosen and medication should be discontinued as promptly as possible.

Atrophic Vaginitis Treatment:

• The treatment of moderate to severe vaginal dryness and pain with intercourse, symptoms of vulvar and vaginal atrophy, associated with menopause can be treated with conjugated estrogens (PV) 2 or estradiol (PV) 3 3.
• Topical vaginal products should be considered when prescribing solely for the treatment of moderate to severe vaginal dryness and pain during intercourse.
• The lowest effective dose and regimen that will control symptoms should be chosen and medication should be discontinued as promptly as possible.

From the Research

Atrophic Vaginitis Treatment Options

• Estrogen replacement therapy is a common treatment for atrophic vaginitis, which can be administered systemically or locally 4.
• The dosage and delivery method of estrogen replacement therapy must be individualized for each patient 4.
• Vaginal moisturizers and lubricants can also be beneficial in the treatment of women with atrophic vaginitis, providing symptomatic relief for vaginal dryness and dyspareunia 4, 5.
• Topical estrogen replacement therapies can reverse mucosal changes and are effective treatments for the symptoms of atrophic vaginitis 5.
• Vaginal estrogen preparations, such as creams, tablets, and rings, are often recommended for women with moderate to severe atrophic vaginitis 6.

Administration of Estrogen Therapy

• Systemic administration of estrogen may not be sufficient for the treatment of atrophic vaginitis-related symptoms, which generally arise after long-term estrogen deficiency 6.
• Vaginal estrogen preparations are more often recommended for women with moderate to severe atrophic vaginitis, as they can provide localized relief from symptoms 6.
• Steady-state plasma concentrations of estrogen are lower after vaginal versus oral administration of conjugated estrogens 7.

Effectiveness and Safety of Estrogen Therapy

• Topical vaginal estrogen preparations can reverse atrophic changes and relieve associated symptoms, while avoiding systemic effects 8.
• The safety and efficacy of estrogen therapy preparations for the treatment of atrophic vaginitis have been evaluated in randomized controlled clinical trials 6.
• Consideration of the potential adverse effects versus associated benefits is necessary when using estrogen therapy 6.