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Treating Vaginal Atrophy with Local Estrogen

NAMS guidelines state that therapy choice should be individualized based on clinical experience and patient preference.

Unlike vasomotor symptoms, the vaginal atrophy accompanying postmenopausal estrogen loss worsens rather than abates with time. Up to 40% of postmenopausal women experience vaginal dryness, vulvovaginal irritation and itching, or dyspareunia, although only about 25% of symptomatic women seek medical help. Localized estrogen delivered by vaginal cream, tablet, or ring is approved for use in North America and can alleviate symptoms without the adverse effects of systemic hormone therapy. The North American Menopause Society (NAMS) has published a position paper on the use of these modalities, based on available evidence. Highlights of the guidelines include the following:

• Management goals are to relieve symptoms and reverse anatomic and physiologic changes associated with diminished estrogen levels.
  
• Nonhormonal lubricants and moisturizers should be used as first-line approaches; symptoms that do not respond to these measures may require hormonal therapy.
  
• Evidence supports the use of low-dose local estrogen as effective and well tolerated, with limited systemic absorption.
  
• All U.S.-approved products — estradiol and conjugated estrogen vaginal creams, the estradiol vaginal ring, and the estradiol vaginal tablet — are equally effective at labeled doses. Progestogen need not be prescribed with these low-dose local estrogens.
  
• Vaginal estrogen therapy should be continued as long as troublesome symptoms persist.
  
• Women at high risk for endometrial cancer who use higher doses of vaginal estrogen or who experience spotting or breakthrough bleeding may need endometrial evaluation. Data are insufficient to recommend annual endometrial evaluation for asymptomatic vaginal estrogen users.
  
• Vaginal atrophy in women with non–hormone-dependent cancers can be treated with vaginal estrogen. Therapy for women with histories of hormone-dependent cancer should be individualized, based on the women’s preferences in consultation with their oncologists.
  

Comment: Symptomatic vaginal atrophy can significantly impair sexual function and intimacy. Women who have been reluctant to use and clinicians who have hesitated to prescribe local vaginal estrogens because of concern about systemic absorption should be encouraged by these findings and recommendations. Because most symptomatic women do not seek medical assistance, clinicians should offer information about vaginal atrophy symptoms and treatments in their menopause counseling and should address this condition with periodic examinations if genital atrophy is identified.

— Diane E. Judge, APN/CNP

Published in Journal Watch Women's Health June 7, 2007

Citation(s):

The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Menopause 2007 May/Jun; 14:370-1.

Reader Remarks:

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• PAINFUL INTERCOURSE
  JOY C. LEHTINEN, 4 May 2009 4:35 PM EST
  I APPRECIATE THIS INFORMATION ABOUT VAGINAL ESTROGEN. MY SEX LIFE HAS BECOME NONEXISTENT DUE TO THE PAIN. I HAVE BEEN... [more]