Managing Menopause, Part 2: Vulvovaginal Atrophy

June 5, 2014

Vaginal dryness from vulvovaginal atrophy is a troublesome symptom of menopause. The good news: many treatments are available for this low-estrogen condition.

Menopause is defined as the absence of menstruation for a full year, as I mentioned in part 1 of this 2-part menopause series (part 1 discussed vasomotor symptoms). The average age of menopause in the United States is 51.3 years, and more than 85% of women will experience symptoms from estrogen deficiency related to this stage in women’s lives. Vasomotor symptoms (VMS), particularly hot flashes and night sweats, are the most common symptoms of menopause. However, vaginal symptoms, specifically vaginal dryness secondary to vulvovaginal atrophy (VVA), have a significant impact on quality of life.

VVA affects up to 45% of women in the United States, but only a fraction of them will address the issue with their medical provider. Furthermore, an even smaller fraction of healthcare providers broach the subject with their patients. This is certainly an area of concern for our patients, and VVA should not be neglected as part of their overall health maintenance.

The hypoestrogenic state associated with menopause results in anatomic and physiologic changes in the female genitourinary tract. These changes include:

- Loss of superficial epithelial cells, causing thinning of these tissues.
- Loss of vaginal rugae.
- Loss of vaginal elasticity.
- Narrowing and shortening of the vagina.
- Loss of subcutaneous fat in the labia majora.
- Diminution of pubic hair.
- Narrowing of the introitus.
- Fusion of the labia minora.
- Shrinking of the clitoral hood (or clitoral prepuce) and urethera.
- Depletion of glycogen in vaginal epithelial cells.
- Diminution of Lactobacilli and subsequent alteration of vaginal flora.
- Alkalization of the vaginal pH.
- Increased risk of genital/vaginal infections and trauma.
- Decreased vaginal secretions, lubrication, and vaginal dryness.

These changes often cause uncomfortable symptoms of vulvovaginal dryness, abnormal discharge, itching, irritation and, most distressing of all, painful sex (dyspareunia). Studies have indicated that the leading cause of hypoactive sexual desire disorder is dyspareunia. Furthermore, up to 55% of postmenopausal women with vaginal dryness have some form of sexual dysfunction. These numbers are even higher in women who are breast cancer survivors. These symptoms can have a negative effect on women's sexual function, self esteem, and overall quality of life.

And a woman doesn’t need to be sexually active to be affected by VVA. In nonsexual women, VVA causes dryness, itching, and irritation. One of the best descriptions I heard from a symptomatic patient was this: "I am dry as sand down there, Doctor. What can I do for this?"

Fortunately, women do not have to suffer in silence. As their health care providers, we can educate our patients about treatment options for this menopausal issue.

Available Treatment Options

The first-line approach for women with mild VVA is nonhormonal local therapies, such as lubricants. When applied before sexual intercourse, lubricants should help relieve friction and subsequently decrease pain related to vaginal dryness during sex.

Table. THERAPEUTIC OPTIONS FOR VAGINAL SYMPTOMS RELATED TO MENOPAUSE
TreatmentDosageEvidence*FDA Approved
Estrogen   
   - Standard       doseConjugated estrogen, 0.625 mg/dYesYes
 Micronized estradiol-17β, 1 mg/dYesYes
 Transdermal estradiol-17β, 

0.0375 – 0.05 mg/dYesYes
   - Low doseConjugated estrogen, 0.3 – 0.45 mg/dYesYes
 Micronized estradiol-17β,

0.5 mg/dYesYes
 Transdermal estradiol-17β,

0.025 mg/dYesYes
  - Ultra-low       doseMicronized estradiol-17β,

0.25 mg/dMixedNo
 Transdermal estradiol-17β,

0.014 mg/dMixedNo
Vaginal/LocalEstradiol-17β ring,

7.5 µg/dYesYes
 Estradiol vaginal tablet, 

25 µg/dYesYes
 Estradiol ring,

0.05 mg/dYes 
 Estradiol-17β cream,

2 g/dYes 
 Conjugated estrogen cream, 0.5–2 g/dYes 
- Raloxifene and tamoxifenNoNo
- Ospemifene60 mg/dYesYes
Vaginal lubricantsYesNo
Vaginal moisturizersYesNo
Herbal remedies and soy productsNoNo

Vaginal moisturizers are also available, and these also can help minimize friction during intercourse. Unlike lubricants, however, vaginal moisturizers cling to the skin and help trap moisture. Although the data on the effectiveness of vaginal moisturizers is limited, these products reportedly help improve vaginal dryness, pH balance, and elasticity and also can help reduce itching.1 Typically, vaginal moisturizers need to be applied more often than just before intercourse, since moisturizers are meant to provide “long-term” relief of vaginal dryness. Some reports cite the effects of an application can last up to 3 or 4 days.

Since the underlying etiology of VVA is the absence of estrogen, it goes without saying that the best treatment for these symptoms is to restore estrogen to the urogenital tissues. If the patient has moderate to severe symptoms from VVA and this causes her more distress than other postmenopausal symptoms, such as VMS, then local topical estrogen is the recommended treatment.

There are multiple modalities-rings, tablets, and creams-and doses to choose from, with the selective estrogen receptor modulator (SERM) ospemifene being the newest option for treatment (Table).

According to the North American Menopause Society, the addition of progestin in women using low-dose vaginal estrogen is no longer indicated.2 Furthermore, clinical trials have demonstrated that local estrogen had no detectable effects on the incidence of venous thromboembolism.3

I usually prescribe the lowest topical dose needed to get results. It is important to evaluate each patient individually and tailor treatment to her specific needs. Educate patients about the proper use of the medication and the importance of maintenance dosing. Also, patients must be aware that the reversal of these changes does not occur overnight. Rather, it often takes two to six weeks before a noticeable change occurs. However, when properly used, these products usually work wonders in a matter of weeks. The results are apparent both on clinical exam and by the patients' level of satisfaction.

References:

1. ACOG practice bulletin no. 141: management of menopausal symptoms. Obstet Gynecol. 2014;123:202-216.

2. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause. 2013;20:888-902. DOI: 10.1097/gme.0b013e3182a122c2

3. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 556: postmenopausal estrogen therapy: route of administration and risk of venous thromboembolism. Obstet Gynecol. 2013;121:887-890.