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Updated Guidance for Vulvovaginal Atrophy

The best first- and second-line therapies for vulvovaginal atrophy are highlighted in an updated position statement from The North American Menopause Society.

After evaluating new evidence on local estrogen and other management options for symptomatic vulvovaginal atrophy (VVA), The North American Menopause Society (NAMS) has updated their position statement on treating the condition.1

Symptomatic VVA is characterized by the symptoms of vaginal dryness, irritation, soreness, and dyspareunia with urinary frequency, urgency, and urge incontinence. Clinical findings may include pale and dry vulvovaginal mucosa with petechiae and the disappearance of vaginal rugae. In addition, the cervix may become flush with the vaginal wall.2 The condition results from a decrease in estrogen levels in the vaginal tissue. Along with symptoms and clinical findings, a diagnosis of VVA is supported by a vaginal pH of 4.6 or greater.

VVA is most prevalent in postmenopausal women but can occur in any woman of any age. The condition is estimated to affect nearly 50% of postmenopausal women, although this estimate may be low as VVA is considered underreported, explains NAMS. The choice of therapy will depend on symptom severity, the safety and efficacy of the therapy for the individual patient, and patient preference.

Women with mild symptoms of VVA generally experience sufficient relief with nonhormonal, over-the-counter therapies, such as vaginal lubricants. Moderate to severe symptoms of VVA are most effectively managed with estrogen therapy.

First-line therapies for symptomatic VVA are simple vaginal lubricants and moisturizers along with regular intercourse or use of a vaginal dilator. If first-line therapy is ineffective, then local or systemic estrogen is the therapeutic standard. Earlier this year, the selective estrogen-receptor modulator ospemifene, marketed under the brand name Osphena, was approved by the FDA for the treatment of moderate to severe dyspareunia and is a nonhormonal option for the management of VVA-related symptoms.3

Low-dose estrogen, applied locally, is the preferred hormonal therapy when symptoms of VVA are the only troublesome symptoms of menopause. Usual practice is that vaginal estrogens can be used without a progestogen if a woman retains her uterus.

It is unknown whether the use of local estrogen in women with breast cancer is safe. Therefore, management of VVA in breast cancer survivors should be guided by the woman’s needs and preferences and in consultation with her oncologist.

Pertinent Points:
- Clinicians can improve the sexual health and quality of life of postmenopausal women through education, diagnosis, and appropriate management of symptomatic VVA.
- Mild symptoms of VVA generally can be managed with nonhormonal over-the-counter lubricants and moisturizers.
- Moderate to severe symptoms of VVA often require treatment with estrogen, either applied vaginally or as part of systemic estrogen therapy.


1. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause. 2013;20:888-902.
2. Mac Bride MB, Rhodes DJ, Shuster LT. Vulvovaginal atrophy. Mayo Clin Proc. 2010;85:87-94.
3. U.S. Food and Drug Administration [news release]. FDA approves Osphena for postmenopausal women experiencing pain during sex. February 26, 2013. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm341128.htm. Accessed August 30, 2013.