What are the treatment options for vulvovaginal (vulvar and vaginal) atrophy?

From the Guidelines

Vulvovaginal atrophy is primarily treated with local estrogen therapy, and the first-line treatment includes vaginal estrogen preparations such as estradiol vaginal tablets, estradiol vaginal ring, or estradiol vaginal cream, as they effectively restore vaginal tissue without significant systemic absorption 1. The treatment of vulvovaginal atrophy (VVA) should prioritize the restoration of vaginal health and the alleviation of symptoms such as dryness, burning, itching, and pain during intercourse.

Treatment Options

• Local estrogen therapy is the most effective treatment for VVA, and it includes vaginal estrogen preparations such as estradiol vaginal tablets (10 mcg inserted vaginally daily for 2 weeks, then twice weekly), estradiol vaginal ring (2 mg, replaced every 90 days), or estradiol vaginal cream (0.5-1 g applied daily for 1-2 weeks, then 1-3 times weekly) 1.
• For women who cannot or prefer not to use estrogen, non-hormonal options include regular use of vaginal moisturizers (applied 2-3 times weekly) and lubricants during sexual activity 1.
• Ospemifene (60 mg daily), a selective estrogen receptor modulator, is approved for treating dyspareunia associated with VVA, but its use should be considered with caution in survivors of estrogen-dependent cancers 1.

Additional Considerations

• Vaginal androgens, such as DHEA, can also be considered for vaginal dryness or pain with sexual activity, but their safety data in survivors of hormonally mediated cancers are limited 1.
• Pelvic floor physical therapy and cognitive behavioral therapy may be useful in decreasing anxiety and discomfort and lowering urinary tract symptoms 1.
• Vaginal dilators may be beneficial in the management of vaginismus and/or vaginal stenosis, particularly in women treated with pelvic radiation therapy 1.

From the FDA Drug Label

OSPHENA is indicated for: 1.1 The Treatment of Moderate to Severe Dyspareunia, a Symptom of Vulvar and Vaginal Atrophy, Due to Menopause. 1.2 The Treatment of Moderate to Severe Vaginal Dryness, a Symptom of Vulvar and Vaginal Atrophy, Due to Menopause. Estradiol valerate injection, USP is indicated in the: Treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with the menopause.

Treatment Options:

• Ospemifene (PO) 60 mg tablet with food once daily 2
• Estradiol valerate injection, USP, for the treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with the menopause 3 Key Considerations:
• Ospemifene should be prescribed for the shortest duration consistent with treatment goals and risks for the individual woman.
• Estradiol valerate injection is also indicated for other conditions, but when prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy, topical vaginal products should be considered.

From the Research

Treatment Options for Vulvovaginal Atrophy

• Topical low-dose estrogens are effective in managing vulvovaginal atrophy (VVA) and can also alleviate urinary incontinence and prevent recurrent urinary tract infections 4
• Non-hormonal preparations, such as lubricants and moisturizers, can be used as first-line treatment for VVA, especially in women taking adjuvant endocrine therapies for hormone-dependent cancers 4, 5
• Sequential treatment, which involves designing a strategy that uses one or more medications for a long enough time to achieve the desired benefits with minimal risk and maximum adherence, is recommended for VVA 5
• Selective estrogen receptor modulators (SERMs), such as ospemifene, can be used to treat VVA-related dyspareunia, but may have a potential venous thrombosis risk 6
• Vaginal dehydroepiandrosterone (DHEA) and laser and radiofrequency treatments are also available options for VVA treatment 5, 7

Individualized Approach to Treatment

• An individualized approach is required for the management of VVA, taking into account the woman's age, symptoms, general health, and treatment preference 4, 7
• The therapeutic management of VVA should follow a sequential order, considering the woman's symptoms, general health, and treatment preference 7
• Beneficial options for VVA treatment include lubricants, moisturizers, vaginal estrogens, androgens, prasterone, and laser application, and the choice of treatment should be tailored to the individual woman's needs 7

Safety and Efficacy of Treatment Options

• The safety data for long-term use of topical estrogens are reassuring, and women should not be denied this treatment if they feel it is beneficial to them 4
• Non-hormonal preparations, such as lubricants and moisturizers, can be used over the long term and are a safe option for women with hormone-dependent cancers 4
• The efficacy of different treatment options for VVA can vary, and the choice of treatment should be based on the individual woman's symptoms and needs 5, 7