Topical estrogens and non-hormonal preparations for postmenopausal vulvovaginal atrophy: An EMAS clinical guide

Abstract

Introduction: Vulvovaginal atrophy (VVA) is a chronic condition caused by estrogen deficiency. It affects around 50% of postmenopausal women, reducing their general and sexual quality of life as well as the quality of their personal relationships. Aim: The aim of this clinical guide is to set out an individualized approach to the management of VVA with topical estrogens and non-hormonal preparations. Materials and methods: Literature review and consensus of expert opinion. Summary recommendations: An individualized approach is required for the management of VVA. Topical low-dose estrogens are effective and also alleviate urinary incontinence and prevent recurrent urinary tract infections. Women should not be denied long-term use of topical estrogens as long as they feel that this treatment is of benefit to them, because the safety data are reassuring. Non-hormonal preparations (lubricants and moisturizers) should be the first-line treatment for VVA in women taking adjuvant endocrine therapies for cancers considered to be hormone-dependent. They can be used over the long term.

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“…Topical lubricants and moisturizers can be used for mild symptoms but symptoms often progress despite their use [3]. Low-dose vaginal estrogen use continues to be controversial in breast cancer survivors [39] but may have a role in some women with breast cancer with severe symptoms after close consultation with the oncologist for discussion of risk with treatment [40,41]. While permitted as second line therapy for dyspareunia by ESO-ESMO international consensus guidelines [42], topical hormone therapy did not improve vaginal symptoms or sexual problems in women with breast cancer in a recent retrospective study [43].…”

The essential menopause curriculum for healthcare professionals: A European Menopause and Andropause Society (EMAS) position statement

“…Symptoms of vulvovaginal atrophy (VVA), which is a component of genitourinary syndrome of the menopause (GSM), are common after the menopause, although they may also occur in pre-and perimenopausal women [12]. They may be lifelong and are experienced by about 50% of postmenopausal women over 60 years of age [13]. Symptoms include dryness, burning, and itching, and dyspareunia may be suffered by both sexually active and inactive women [13].…”

“…They may be lifelong and are experienced by about 50% of postmenopausal women over 60 years of age [13]. Symptoms include dryness, burning, and itching, and dyspareunia may be suffered by both sexually active and inactive women [13]. They can also be associated with urinary tract problems, such as frequent urination, urge incontinence and recurrent urinary tract infections.…”

“…Micronized progesterone or synthetic progestogens are added in regimens for nonhysterectomized women to reduce the increased risk of endometrial hyperplasia and carcinoma which occurs with unopposed estrogen. However, women who take low-dose vaginal estrogen do not need to take a progestogen [13,23]. The routes of administration for estrogen are oral, transdermal (patches, gels and spray), subcutaneous (implants) and vaginal.…”

“…Many lubricants and vaginal moisturizers are available for use by women experiencing vaginal dryness [13]. Lubricants are typically used episodically to correspond to sexual activity.…”