madman
Super Moderator
ABSTRACT
Introduction: Despite its frequency, recognition and therapy of vulvovaginal atrophy (VVA) remain suboptimal. Wet mount microscopy, or vaginal pH as a proxy, allows VVA diagnosis in menopause, but also in young contraception users, after breast cancer, or postpartum. Intravaginal low-dose estrogen product is the main therapy. Ultra-low-dose vaginal estriol is safe and sufficient in most cases, even in breast cancer patients, while hyaluronic acid can help women who cannot or do not want to use hormones.
Areas covered: The authors provide an overview of the current pharmaceutical treatment for vulvovaginal atrophy and provide their expert opinions on its future treatment.
Expert opinion: The basis of good treatment is a correct and complete diagnosis, using a microscope to study the maturity index of the vaginal fluid. A minimal dose of estriol intravaginally with or without lactobacilli is elegant, cheap, and can safely be used after breast cancer and a history of thromboembolic disease. Laser therapy requires validation and safety data, as it can potentially cause vaginal fibrosis and stenosis, and safer and cheaper alternatives are available.
Article highlights
● Despite its frequency, vulvovaginal atrophy (VVA, part of GenitoUrinary Syndrome of Menopause) is underdiagnosed and undertreated, but a proper and complete diagnosis is essential for designing a good therapy and follow-up
● Although vaginal pH measurement can be used as a proxy, wet mount microscopy of vaginal fluid is superior to diagnose VVA by calculating the vaginal epithelial cell maturity index, but also to exclude infections and inflammation
● Local estrogens are the cornerstone of treatment, while systemic estrogens are reserved for patients with more menopausal symptoms. Although any type of locally applied estrogen is efficient, synthetic as well as biological, the safest and lowest dose should be used
● Novel hormonal therapies, such as dehydroepiandrosterone sulfate, ospemifene, estretol, are efficient, but their risks of complications like breast cancer and thromboembolism require further studies
● Women with contraindications for hormonal use such as breast cancer or previous thromboembolism should be tried on nonhormonal therapies, such as hyaluronic acid but if insufficient, use of ultralow-dose of locally applied estriol with or without lactobacilli can be a safe alternative
● Mechanical therapies like applying radiofrequency or laser waves to the vagina lack proper randomized studies comparing their efficacy to standard estrogen therapy, and proving their safety to prevent later scarring and stenosis of the vagina. This box summarizes key points contained in the article
5. Conclusion
Several safe and efficient therapies are optional for the treatment of vulvovaginal atrophy, both hormonal and non-hormonal. After trying nonhormonal moistening products, a first-line therapy, intravaginal application of a low-dose estrogen product is recommended, unless more generalized menopausal symptoms demand systemic treatment (Figure 3). For women with contra-indications for estrogen therapy, nonhormonal therapy such as hyaluronic acid or laser therapy is possible, but also ultra-low-dose of estriol, with or without combined probiotic lactobacilli, seems safe and very efficacious. Laser therapy cannot be recommended until randomized studies prove its efficacy and safety, especially in the long term.
Introduction: Despite its frequency, recognition and therapy of vulvovaginal atrophy (VVA) remain suboptimal. Wet mount microscopy, or vaginal pH as a proxy, allows VVA diagnosis in menopause, but also in young contraception users, after breast cancer, or postpartum. Intravaginal low-dose estrogen product is the main therapy. Ultra-low-dose vaginal estriol is safe and sufficient in most cases, even in breast cancer patients, while hyaluronic acid can help women who cannot or do not want to use hormones.
Areas covered: The authors provide an overview of the current pharmaceutical treatment for vulvovaginal atrophy and provide their expert opinions on its future treatment.
Expert opinion: The basis of good treatment is a correct and complete diagnosis, using a microscope to study the maturity index of the vaginal fluid. A minimal dose of estriol intravaginally with or without lactobacilli is elegant, cheap, and can safely be used after breast cancer and a history of thromboembolic disease. Laser therapy requires validation and safety data, as it can potentially cause vaginal fibrosis and stenosis, and safer and cheaper alternatives are available.
Article highlights
● Despite its frequency, vulvovaginal atrophy (VVA, part of GenitoUrinary Syndrome of Menopause) is underdiagnosed and undertreated, but a proper and complete diagnosis is essential for designing a good therapy and follow-up
● Although vaginal pH measurement can be used as a proxy, wet mount microscopy of vaginal fluid is superior to diagnose VVA by calculating the vaginal epithelial cell maturity index, but also to exclude infections and inflammation
● Local estrogens are the cornerstone of treatment, while systemic estrogens are reserved for patients with more menopausal symptoms. Although any type of locally applied estrogen is efficient, synthetic as well as biological, the safest and lowest dose should be used
● Novel hormonal therapies, such as dehydroepiandrosterone sulfate, ospemifene, estretol, are efficient, but their risks of complications like breast cancer and thromboembolism require further studies
● Women with contraindications for hormonal use such as breast cancer or previous thromboembolism should be tried on nonhormonal therapies, such as hyaluronic acid but if insufficient, use of ultralow-dose of locally applied estriol with or without lactobacilli can be a safe alternative
● Mechanical therapies like applying radiofrequency or laser waves to the vagina lack proper randomized studies comparing their efficacy to standard estrogen therapy, and proving their safety to prevent later scarring and stenosis of the vagina. This box summarizes key points contained in the article
5. Conclusion
Several safe and efficient therapies are optional for the treatment of vulvovaginal atrophy, both hormonal and non-hormonal. After trying nonhormonal moistening products, a first-line therapy, intravaginal application of a low-dose estrogen product is recommended, unless more generalized menopausal symptoms demand systemic treatment (Figure 3). For women with contra-indications for estrogen therapy, nonhormonal therapy such as hyaluronic acid or laser therapy is possible, but also ultra-low-dose of estriol, with or without combined probiotic lactobacilli, seems safe and very efficacious. Laser therapy cannot be recommended until randomized studies prove its efficacy and safety, especially in the long term.
