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ABSTRACT
Introduction
Proper recognition and individualized therapy of vulvovaginal atrophy (VVA) is paramount.
Areas covered
Assessment of VVA should be performed using several questionnaires in combination with wet mount microscopy to determine Vaginal Cell Maturation Index (VCMI) and infections. PubMed searches were carried out between 1 march 2022 and 15 October 2022.
Low dose vaginal estriol seems safe, efficient, and could be used in patients with contraindications for steroid hormones such as women with a history of breast cancer, and should therefore be considered as first choice hormonal treatment, when non-hormonal treatments fail. New estrogens, androgens, and several Selective Estrogen Receptor Modulators (SERMs) are being developed and tested. Intravaginal Hyaluronic Acid (HA) or Vit D can help women who can’t or don’t want to use hormones.
Expert opinion
Proper treatment is not possible without a correct and full diagnosis, including microscopy of the vaginal fluid. Low dose vaginal estrogen treatment, especially with estriol, is very efficient and is preferred in most women with VVA. Oral ospemifene and vaginal dihydroepiandrosterone (DHEA) are now considered efficient and safe alternative therapies for VVA. More safety data are waited for several SERMs and for a newly introduced estrogen: estetrol (E4), although so far no major side effects were seen from these drugs. Indications for laser treatments are questionable.
Article highlights
Despite its frequency and increasing importance, VVA is still underdiagnosed and inconsistently treated.
Precise and complete diagnosis is essential for designing best therapy and follow-up.
Although vaginal pH measurement can be used as a proxy, VCMI by phase contrast wet mount microscopy of vaginal fluid is a superior tool to diagnose VVA.
Non-hormonal treatments can be used. However, the threshold should be low to use low dose vaginal estrogens, considering their high safety profile. They form a cornerstone in the treatment of VVA (and genito-urinary syndrome of menopause in general).
In the presence of associated general menopausal symptoms or health risks and in the absence of contra-indications, systemic estrogens can be used.
The safest and lowest dose of any estrogen, synthetic or biological, should be used in order to minimize any potential complication risks.
Newer hormonal therapies, such as DHEA and ospemifene, are efficient and safe for use as alternative therapies. DHEA may have some extra advantages in women who suffer from sexual dysfunction. Further studies to ensure their long safety for complications like breast cancer and thrombo-embolism remain important.
Women who have contraindications for hormonal use such as a history of breast cancer or thromboembolism, can try non-hormonal therapies as a first line, such as hyaluronic acid or vitamin D. If insufficient, ultra-low dose of locally applied estriol with or without lactobacilli is a safe alternative. Based on recent safety data DHEA or ospemifene also seem potentially safe to use in these patients. We advise for safety trials specifically in these populations.
Estetrol (E4) is a promising new drug with good safety profile, but endometrial proliferation needs to be surveilled.
Radiofrequency or laser wave therapies should not be applied to the vagina as long as we lack proper randomized studies comparing their efficacy and safety to standard estrogen therapy.
Declaration of interest
G Donders was involved in clinical studies assessing ospemifene and low dose estriol plus lactobacilli effects on vulvovaginal atrophy. 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 apart from those disclosed.
Reviewer disclosures
A reviewer on this manuscript has disclosed receiving a speaker fee from Deka laser. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.