Treatment for Vaginal Dryness

We know that one quarter of women at or past menopause note vaginal thinning, irritation, decreased sexual response or dryness, and seek medical attention for it. I find the numbers are actually much higher if you ask women routinely. I'm a big fan of natural lubricants first, and if that doesn't work, try a tiny dose of natural estriol vaginal cream. I like estriol because you usually need less of it than the other forms of estradiol. It is by prescription, and needs to be formulated by a reliable compounding pharmacy. The good news is that it takes about 2 weeks to re-estrogenize the tissues, and it also prevents bladder infections. Remember that pre-menopausal women can have thiss too -- especially thin women who don't have much estrogen on board. Below are some guidelines, published by the North American Menopause Society.
SG

New Guidelines Issued for Treatment of Vaginal Atrophy
News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD

May 15, 2007 — The North American Menopause Society (NAMS) has issued a 2007 position statement about the treatment of vaginal atrophy with local vaginal estrogen. The guidelines, which are published in the May-June issue of Menopause, state that therapy should be guided by clinician and patient preference.

Using the general principles established for evidence-based guidelines, NAMS convened a panel of clinicians and researchers with expertise in genitourinary disease to review, synthesize, and interpret the current evidence on vaginal estrogen therapy for vaginal atrophy, develop conclusions, and make recommendations. The advice of this expert panel was used to assist the NAMS Board of Trustees in publishing this position statement.

"Although hot flashes typically accompany the loss of ovarian estrogen production at menopause, they usually abate over time regardless of whether estrogen therapy is used," Editorial Board Chair Gloria A. Bachmann, MD, said in a news release. "In contrast, vaginal symptoms (eg, vaginal dryness, vulvovaginal irritation and itching, and painful intercourse) are usually progressive and unlikely to resolve spontaneously. Left untreated, vaginal atrophy can result in years of discomfort, with a significant impact on quality of life."

About 10% to 40% of postmenopausal women have symptoms related to vaginal atrophy, most of whom require treatment. However, only about 25% of symptomatic women seek medical attention.

The therapeutic standard for moderate to severe vaginal atrophy is estrogen therapy, administered either vaginally at a low dose or systemically. There has been a relative lack of randomized controlled trials performed to date, but they have shown that low-dose, local vaginal estrogen delivery is effective and well tolerated for treating vaginal atrophy.

In North America, US Food and Drug Administration–approved treatments of vaginal atrophy symptoms that offer localized vaginal delivery of estrogen include cream, tablet, and ring formulations. These products are associated with fewer adverse effects than systemic estrogen. At the doses recommended in labeling, all of the low-dose vaginal estrogen products approved in the United States for treatment of vaginal atrophy are equally effective. The choice of treatment should therefore be individualized based on clinical experience and patient preference.

In general, creams may be associated with more adverse effects than ring or tablet formulations, perhaps because there is more potential for women to apply higher-than-recommended dosing with cream. However, a Cochrane review reported no significant differences among the delivery methods in terms of hyperplasia, endometrial thickness, or the proportion of women with adverse events. The most commonly reported adverse effects associated with vaginal estrogen therapy are vaginal bleeding and breast pain, with nausea and perineal pain reported less frequently.

When low-dose estrogen is administered locally for vaginal atrophy, progestogen is generally not indicated. Data are insufficient to recommend annual endometrial surveillance in asymptomatic women using vaginal estrogen therapy.

Vaginal estrogen therapy should be continued as long as women continue to have distressing symptoms. Management of vaginal atrophy is similar for the group of women without a cancer history and for women treated for non–hormone-dependent cancer. However, for women with a history of hormone-dependent cancer, management recommendations are individualized and vary based on each woman's preference in consultation with her oncologist.

Specific recommendations are as follows:

The primary goals of vaginal atrophy management are symptom relief and reversal of atrophic anatomic changes.

For women with vaginal atrophy, first-line treatments include nonhormonal vaginal lubricants and moisturizers.

Symptomatic vaginal atrophy that does not respond to nonhormonal vaginal lubricants and moisturizers may require prescription therapy.

Randomized controlled trials in postmenopausal women are limited. However, they have demonstrated that low-dose, local, prescription vaginal estrogen delivery is effective and well tolerated for treating vaginal atrophy while limiting systemic absorption.

Low-dose vaginal estrogen products approved in the United States for treating vaginal atrophy include estradiol vaginal cream, conjugated estrogens vaginal cream, the estradiol vaginal ring, and the estradiol hemihydrate vaginal tablet. These are equally effective at the doses recommended in labeling, so specific choice depends on clinical experience and patient preference.

When low-dose estrogen is administered locally for vaginal atrophy, progestogen is generally not indicated.

Closer surveillance may be required for women at high risk for endometrial cancer, those using a higher dose of vaginal estrogen therapy, or those with symptoms such as spotting or breakthrough bleeding. Evidence is insufficient to recommend annual endometrial surveillance in asymptomatic women using vaginal estrogen therapy.

Vaginal estrogen therapy should be continued for as long as women have distressing symptoms.

For women treated for non–hormone-dependent cancer, management of vaginal atrophy is similar to that for women without a cancer history, but for those with a history of hormone-dependent cancer, management recommendations should be based on each woman's preference and the advice of her oncologist.
"Overall, subjective improvement occurs in 80% to 90% of women treated with local vaginal estrogen," the authors conclude. "Vaginal atrophy unresponsive to estrogen may be due to undiagnosed dermatitis/dermatosis or vulvodynia, so treatment failure warrants future evaluation and careful examination."

Novo Nordisk supported the development of this position statement through an unrestricted educational grant. Members of the Editorial Board have disclosed various financial relationships with Berlex, Duramed, Johnson & Johnson, Pfizer, Roche, Wyeth, Paladin Labs Canada, Wyeth Canada, Procter & Gamble, and/or Merck.

Menopause. 2007;14:357-369.