NC.com

Description

• Characteristics: vulvovaginal (dryness, burning, irritation), urinary (urgency, frequency, dysuria, rUTI), sexual (dyspareunia, vaginal bleeding)
• Prevalence: 13-87% of postmenopausal women

Evaluation

• At-risk patients: post-menopause, primary ovarian insufficiency, oral contraceptive use, chemotherapy exposure, surgically-induced menopause
• Symptoms: genital dryness, decreased lubrication, dyspareunia, discomfort with tight clothing, post-coital bleeding, irritation/burning, dysuria, urinary frequency or urgency, decreased arousal or desire
• Signs: decreased moisture, loss of vaginal rugae, vaginal pallor, decreased elasticity, introital retraction, introital stenosis, tissue fragility or fissures, urethral caruncle/prolapse, recurrent UTI
• Exam assess vulva, vestibule, vagina, urethra, clitoris

Medication options

Category	Composition	Starting dose	Maintenance dose	Expected serum level
Vaginal creams	17B-estradiol 0.01%	0.5-1g/d x2wk	0.5-1g 1-3x/wk	Variable
	Conjugated estrogen
Vaginal inserts	17B-estradiol inserts	4 or 10ug/d x2wk	1 insert 2x/wk	3.6-4.6pg/mL
	Estradiol hemihydrate tablets			5.5pg/mL
	Prasterone (DHEA) inserts	6.5mg/d	1 insert/d	5pg/mL
Vaginal rings	Silicone polymer w/ 2mg estradiol	7.5ug/d x3mo	q3mo exchanges	8pg/mL
Oral tablet	Ospemifene	60mg/d		n/a

Other options

• Other hormonal options: no strong evidence for vaginal/systemic testosterone or vaginal oxytocyn
• Lubricant/moisturizer: beneficial for patients with dryness and dyspareunia
• Natural supplements: no good evidence
• Lasers: no good evidence for use of CO2 or ER:YAG for and GUSM treatments

Treatment risks

• Breast cancer: no proven link to vaginal estrogen cream, DHEA, or ospemifene, safe to use in breast cancer survivors, does not raise systemic estrogen levels
• Endometrial hyperplasia/cancer: no proven link to vaginal estrogen cream, DHEA, or ospemifene
• Side effects: DHEA and ospemifene may cause flushing or vaginal discharge, vaginal estrogen has no clear side effects
• Need for endometrial surveillance: no proven benefit as risk for hyperplasia is very low