Abstract
Vulvovaginal atrophy is a frequently neglected symptom of menopause. While an estimated 10–40% of women are affected by the progressive symptoms of vaginal dryness, irritation, itching, dysuria and dyspareunia, only a quarter of symptomatic women are believed to seek medical attention. Until recently, treatments for vulvovaginal atrophy were limited to often insufficient or inappropriate oral estrogen therapies and over-the-counter lubricants and moisturizers. Currently, a broader range of treatments, which address symptom reduction and estrogen restoration to affected tissue, are being developed. Among these treatments are local estrogen, selective estrogen receptor modulators, tissue-selective estrogen complexes, local androgens, dehydroepiandrosterone, oxytocin, phytoestrogens and nonhormonal options. The aim of this article is to discuss current treatments for vulvovaginal atrophy. In addition, we will discuss alternative therapies and explore emerging strategies for care.
Financial & competing interests disclosure
Goldstein AT is a consultant for Neogyn and Emotional Brain. 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.
No writing assistance was utilized in the production of this manuscript.
Key issues
• Vulvovaginal atrophy, which can have a large impact on quality of life and sexual function, is often underdiagnosed and undertreated.
• The symptoms of vulvovaginal atrophy, such as vaginal dryness, irritation, itching, dysuria and dyspareunia, are caused by loss of estrogen production during menopause.
• In addressing symptoms of vulvovaginal atrophy, particular attention to the vulvar vestibule is recommended as atrophy-related dyspareunia and dryness are often focused to the vestibule.
• Local estrogen therapy is the treatment of choice for women with vulvovaginal atrophy who lack other postmenopausal symptoms.
• Systemic estrogen therapy is indicated for vulvovaginal atrophy only for women with menopausal vasomotor symptoms.
• SERMs ospemifine (Osphena) and lasofoxifene (Oporia) are effective for treatment of vulvovaginal atrophy. Osphena was recently FDA approved for this purpose.
• TSECs are being developed with the goal of relieving both systemic and local symptoms of menopause. BZA/CE has showed benefits in treating vulvovaginal atrophy symptoms in Phase III trial.
• Recent studies reveal ARs in vaginal tissue. A small pilot study of vaginal testosterone showed improvement in vaginal atrophy without increasing estradiol levels.
• Intravaginal DHEA has been found to improve vulvovaginal atrophy symptoms by acting on all three layers of the vagina.
• Oxytocin and phytoestrogens are being explored to provide treatment alternatives to hormonal therapy.
• Nonhormonal treatments, such a lubricants, moisturizers and pH-balanced gels, may have benefits in symptomatic relief of vulvovaginal atrophy.