Pharmacotherapy for the treatment of vaginal atrophy

ABSTRACT

Introduction: Despite its frequency, recognition and therapy of vulvovaginal atrophy (VVA) remain suboptimal. Wet mount microscopy, or vaginal pH as a proxy, allows VVA diagnosis in menopause, but also in young contraception users, after breast cancer, or postpartum. Intravaginal low dose estrogen product is the main therapy. Ultra-low-dose vaginal estriol is safe and sufficient in most cases, even in breast cancer patients, while hyaluronic acid can help women who cannot or do not want to use hormones.

Areas covered: The authors provide an overview of the current pharmaceutical treatment for vulvovaginal atrophy and provide their expert opinions on its future treatment.

Expert opinion: The basis of good treatment is a correct and complete diagnosis, using a microscope to study the maturity index of the vaginal fluid. Minimal dose of estriol intravaginally with or without lactobacilli is elegant, cheap and can safely be used after breast cancer and history of thromboembolic disease. Laser therapy requires validation and safety data, as is can potentially cause vaginal fibrosis and stenosis, and safer and cheaper alternatives are available.

KEYWORDS:

• Genito-urinary syndrome of menopause
• steroid hormones
• estrogen
• therapy
• lactobacillary grades
• vaginal cell maturity

Article highlights

• Despite its frequency, vulvovaginal atrophy (VVA, part of Genito-Urinary Syndrome of Menopause) is underdiagnosed and undertreated, but a proper and complete diagnosis is essential for designing a good therapy and follow-up.

• Although vaginal pH measurement can be used as a proxy, wet mount microscopy of vaginal fluid is superior to diagnose VVA by calculating the vaginal epithelial cell maturity index, but also to exclude infections and inflammation.

• Local estrogens are the cornerstone of treatment, while systemic estrogens are reserved for patients with more menopausal symptoms. Although any type of locally applied estrogen is efficient, synthetic as well as biological, the safest and lowest dose should be used.

• Novel hormonal therapies, such as dehydroepiandrosterone sulfate, ospemifene, estretol, are efficient, but their risks on complications like breast cancer and thromboembolism require further studies.

• Women with contraindications for hormonal use such as breast cancer or previous thromboembolism should be tried on nonhormonal therapies, such as hyaluronic acid but if insufficient, use of ultra-low-dose of locally applied estriol with our without lactobacilli can be a safe alternative.

• Mechanical therapies like applying radiofrequency or laser waves to the vagina lack proper randomized studies comparing their efficacy to standard estrogen therapy, and to prove their safety to prevent later scarring and stenosis of the vagina.

This box summarizes key points contained in the article.

Declaration of interest

G Donders and K Ruban are active employees of Femicare vzw (with GD as president) while G Bellen and S Grinceviciene are both former employees (G Bellen was an employee of Femicare at the time of writing the review) The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

One referee declares that they participated in a working group which came up with term "GSM" while another declares past financial relationships (as lecturer, member of advisory boards and/or consultant) with Boehringer Ingelheim, Ely Lilly, Gedeon Richter, HRA Pharma, Pfizer Inc, Procter & Gamble Co, TEVA Women’s Health Inc, Zambon SpA. Furthermore, at present, they have on-going relationships with Bayer HealthCare AG, Endoceutics, Exceltis, Merck Sharpe & Dohme, Novo Nordisk, Palatin Technlogies, Shionogi Limited, Theramex. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This manuscript has not been funded.