For women in menopause, narrowing and thinning of the vaginal tissues and vaginal dryness, a condition called vulvovaginal atrophy (VVA) is one of the most common symptoms. Though it affects over half of women, only 7% are treated and many are unaware that effective treatments are available. Typical symptoms are vaginal dryness that can lead to painful sex and burning with urination and recurring urinary tract infections. For 64% of women with VVA, these symptoms lead to painful sex, loss of libido and even avoidance of intimacy. For 29% of women, VVA indicated that it had a negative effect on sleep.
At the present time, the North American Menopause Society (NAMS) indicated in a new position statement that estrogen therapy is still the primary treatment for moderate-to-severe symptoms but long-term studies on the safety of local estrogen on the uterine lining are lacking. Long term uterine lining safety information is also lacking for ospemifene, a newly approved non-estrogen treatment for VVA. Fortunately, safety can be easily tested with either uterine ultrasound measurements or endometrial biopsy, a minor office procedure that tests the cells of the uterine lining.
NAMS also reviewed over-the-cover therapies in the United States and Canada, such as vaginal lubricants and moisturizers, as well as prescriptions available such as vaginal estrogen, hormone therapy, and the selective estrogen-receptor modulator ospemifene. The best therapy for VVA really depends on how severe the symptoms, patient preference and how effective and safe the therapy is for a particular patient.
Although estrogen and ospemifene have never been studied together, the position statement indicates that estrogen is the most effective therapy for moderate to severe symptoms. If a woman has had her uterus removed (hysterectomy) a progestogen hormone is not required and generally is not needed for women who have not had their uterus removed and who are prescribed low-dose local estrogen. However, there is still too little information to be absolutely certain that local estrogen is safe for women with breast cancer and the safety of estrogen on the uterine lining has not been studied in clinical trials beyond 1 year.
For most women with mild VVA symptoms, non-hormonal over-the-counter therapies are often effective. Because these symptoms are so common and because so few women are treated, it’s important for both women to tell their doctors about their symptoms and for more doctors to ask about these symptoms to lower the potentially significant impact VVA can have on their sexual health and quality of life.
