madman
Super Moderator
ABSTRACT
Objective: To develop a best practice document for the management of postmenopausal vulvovaginal atrophy (VVA).
Method: Literature review carried out using clinical terms, treatments or interventions, and comorbidity related to VVA.
Results: There is a wide variety of interventions that may produce temporal benefits for VVA. However, there are significant limitations in scientific publications concerning VVA and related issues, including variable outcome evaluations, variability in population age range, and small, often underpowered sample sizes. Therapeutic management of VVA should follow a sequential order, considering women’s age, symptoms, general health as well as treatment preference. Beneficial options include lubricants, moisturizers, vaginal estrogens (estradiol, estriol, promestriene, conjugated estrogens), androgens, prasterone, and laser application. In women with general menopausal symptoms who are candidates for systemic hormone therapy, the lowest effective dose should be used. Oral ospemifene is an effective selective estrogen receptor modulator to treat VVA. Systemic androgens have a limited role. Although laser procedures are commonly used, at this moment the International Society for the Study of Vulvovaginal Disease does not endorse its use out of the setting of clinical trials. Pelvic floor muscle training improves blood flow and elasticity of the vulvovaginal tissue. In breast cancer survivors, moisturizers and lubricants are first-line therapy. However, limited absorption of low/ultra-low doses of estrogens suggests safety, especially in women under treatment with aromatase inhibitors. As a clinical practice and available preparations vary between countries this text should be adapted to local circumstances.
Conclusions: There is a wide range of therapeutic options to individualize VVA treatments.
Introduction
The vaginal wall has estrogen, progesterone, and androgen receptors [1–3]. During the reproductive years, the female genital tract maintains its trophism under the stimulus of both estrogens and progesterone. After menopause the entire genital tract becomes atrophic. Androgens also play a significant role, directly and indirectly (aromatization to estrogens), in the trophism of the lower genital tract [1,4,5]. Vulvovaginal atrophy (VVA) is the most prevalent menopause-related clinical entity, continuously worsening if untreated. It is associated with dryness, dyspareunia, sexual dysfunction, nocturia, dysuria, recurrent urinary infection, and reduction of quality of life [6]. The severity of symptoms is related to the time elapsed since menopause and the frequency of sexual rapport. Surgical menopause or pelvic irradiation produces more severe symptoms in women during reproductive years due to the abrupt steroid decline. Many women attempt to relieve symptoms with over-the-counter products (moisturizers and/or lubricants), while others refer to a gynecologist or other health care professionals [7]. The treatment depends on symptoms, age, overall health, presence of other climacteric symptoms, and health risks.
*Vaginal estrogen therapy
*Vaginal androgen therapy
The labia majora, labia minora, vulvar vestibule, vestibular glands, vaginal mucosa, clitoris, and urethra are dependent on androgens for optimal function. In the vagina, it suppresses the inflammatory response of the smooth muscle cells [1] and is essential in regulating arousal and lubrication, modulating nociception, and mucin secretion [1,5].
-Vaginal prasterone
-Vaginal testosterone
*Vaginal lubricants and moisturizers
*Vaginal laser
*Systemic hormone treatments
-Menopause hormone therapy
-Selective estrogen receptor modulators
-Systemic androgens
*Pelvic floor rehabilitation
*Vulvovaginal atrophy in breast cancer survivors
-Vaginal estrogens in breast cancer survivors
-Vaginal androgens in breast cancer survivors
-Laser treatment in cancer survivors
Final remarks
Therapeutic management of VVA should follow a sequential order, considering women’s age, symptoms, and general health as well as previous treatment and patient preference. This will contribute to compliance and adhesion. Lifestyle, co-morbidity, and chronic diseases may also influence the election of treatment. Table 1 summarizes current treatment options to manage VVA. Vaginal options that produce benefits for VVA include lubricants and moisturizers, estrogens (estradiol, estriol, promestriene), or prasterone. Although laser procedures are currently used, at this moment the ISSVD does not endorse its use outside of the setting of clinical trials.
The lowest effective dose of systemic hormone therapy should be used to treat VVA and only in women with other menopausal symptoms and without contraindications. Oral ospemifene is an effective SERM to treat VVA. Systemic androgens have a limited role and are not indicated to treat VVA. Pelvic floor muscle training improves blood flow and elasticity of the vulvovaginal tissue. In breast cancer survivors, moisturizers and lubricants are first-line therapy. Some evidence suggests that women under treatment with aromatase inhibitors might be treated with low doses of vaginal estriol, and experts believe that the receptor-blocking action of tamoxifen may improve the safety of estrogen therapies.
Follow-up of therapeutic interventions should be individualized, and treatments should be monitored at appropriate intervals. As a clinical practice and available preparations may vary from country to country this text should be adapted to local circumstances.
Objective: To develop a best practice document for the management of postmenopausal vulvovaginal atrophy (VVA).
Method: Literature review carried out using clinical terms, treatments or interventions, and comorbidity related to VVA.
Results: There is a wide variety of interventions that may produce temporal benefits for VVA. However, there are significant limitations in scientific publications concerning VVA and related issues, including variable outcome evaluations, variability in population age range, and small, often underpowered sample sizes. Therapeutic management of VVA should follow a sequential order, considering women’s age, symptoms, general health as well as treatment preference. Beneficial options include lubricants, moisturizers, vaginal estrogens (estradiol, estriol, promestriene, conjugated estrogens), androgens, prasterone, and laser application. In women with general menopausal symptoms who are candidates for systemic hormone therapy, the lowest effective dose should be used. Oral ospemifene is an effective selective estrogen receptor modulator to treat VVA. Systemic androgens have a limited role. Although laser procedures are commonly used, at this moment the International Society for the Study of Vulvovaginal Disease does not endorse its use out of the setting of clinical trials. Pelvic floor muscle training improves blood flow and elasticity of the vulvovaginal tissue. In breast cancer survivors, moisturizers and lubricants are first-line therapy. However, limited absorption of low/ultra-low doses of estrogens suggests safety, especially in women under treatment with aromatase inhibitors. As a clinical practice and available preparations vary between countries this text should be adapted to local circumstances.
Conclusions: There is a wide range of therapeutic options to individualize VVA treatments.
Introduction
The vaginal wall has estrogen, progesterone, and androgen receptors [1–3]. During the reproductive years, the female genital tract maintains its trophism under the stimulus of both estrogens and progesterone. After menopause the entire genital tract becomes atrophic. Androgens also play a significant role, directly and indirectly (aromatization to estrogens), in the trophism of the lower genital tract [1,4,5]. Vulvovaginal atrophy (VVA) is the most prevalent menopause-related clinical entity, continuously worsening if untreated. It is associated with dryness, dyspareunia, sexual dysfunction, nocturia, dysuria, recurrent urinary infection, and reduction of quality of life [6]. The severity of symptoms is related to the time elapsed since menopause and the frequency of sexual rapport. Surgical menopause or pelvic irradiation produces more severe symptoms in women during reproductive years due to the abrupt steroid decline. Many women attempt to relieve symptoms with over-the-counter products (moisturizers and/or lubricants), while others refer to a gynecologist or other health care professionals [7]. The treatment depends on symptoms, age, overall health, presence of other climacteric symptoms, and health risks.
*Vaginal estrogen therapy
*Vaginal androgen therapy
The labia majora, labia minora, vulvar vestibule, vestibular glands, vaginal mucosa, clitoris, and urethra are dependent on androgens for optimal function. In the vagina, it suppresses the inflammatory response of the smooth muscle cells [1] and is essential in regulating arousal and lubrication, modulating nociception, and mucin secretion [1,5].
-Vaginal prasterone
-Vaginal testosterone
*Vaginal lubricants and moisturizers
*Vaginal laser
*Systemic hormone treatments
-Menopause hormone therapy
-Selective estrogen receptor modulators
-Systemic androgens
*Pelvic floor rehabilitation
*Vulvovaginal atrophy in breast cancer survivors
-Vaginal estrogens in breast cancer survivors
-Vaginal androgens in breast cancer survivors
-Laser treatment in cancer survivors
Final remarks
Therapeutic management of VVA should follow a sequential order, considering women’s age, symptoms, and general health as well as previous treatment and patient preference. This will contribute to compliance and adhesion. Lifestyle, co-morbidity, and chronic diseases may also influence the election of treatment. Table 1 summarizes current treatment options to manage VVA. Vaginal options that produce benefits for VVA include lubricants and moisturizers, estrogens (estradiol, estriol, promestriene), or prasterone. Although laser procedures are currently used, at this moment the ISSVD does not endorse its use outside of the setting of clinical trials.
The lowest effective dose of systemic hormone therapy should be used to treat VVA and only in women with other menopausal symptoms and without contraindications. Oral ospemifene is an effective SERM to treat VVA. Systemic androgens have a limited role and are not indicated to treat VVA. Pelvic floor muscle training improves blood flow and elasticity of the vulvovaginal tissue. In breast cancer survivors, moisturizers and lubricants are first-line therapy. Some evidence suggests that women under treatment with aromatase inhibitors might be treated with low doses of vaginal estriol, and experts believe that the receptor-blocking action of tamoxifen may improve the safety of estrogen therapies.
Follow-up of therapeutic interventions should be individualized, and treatments should be monitored at appropriate intervals. As a clinical practice and available preparations may vary from country to country this text should be adapted to local circumstances.
