Local Estrogen Treatment Options for Vaginal Atrophy
CLINICAL ACTIONS:
A growing number of estrogen treatment options are available for postmenopausal vaginal atrophy. Vulvovaginal atrophy is a common symptom of atrophic vaginitis (also referred to as the genitourinary syndrome of menopause or GSM) and can occur in both perimenopausal and postmenopausal women. If a patient reports vaginal dryness, consider the following
Establish a diagnosis of postmenopausal atrophy based on thorough history and physical exam
Confirm with an appropriate pelvic/ vaginal exam
Discuss use of estrogen, understanding that for some women based on medical history, systemic estrogen might not be an appropriate option
Even with a personal history of cancer, local estrogen may be an appropriate treatment (see ‘Key Points’ and ‘Related ObG Topics’ below) depending on the clinical scenario
Vaginal estrogens can be prescribed as
A cream inserted twice weekly using an applicator
A tablet inserted with an applicator
A soft gel pellet inserted twice weekly with no applicator (FDA approved May, 2018)
Ring made of silicone elastomere containing a drug core of estradiol hemihydrate (replaced every 3 months)
Local Estrogen Routes and Dosing for GSM
Estradiol-17β ring (releases 7.5 micrograms/d)
Replace every 3 months
Estradiol vaginal tablet (10 micrograms/d)
Place nightly for 2 weeks
Maintenance is one tablet 2 times/week
Note: this is the corrected dose in ACOG PB 141
Estradiol-17β cream (0.1 mg active ingredient/g)
2-4 g/d for 1 to 2 weeks
Gradually reduce to ½ initial dosage for 1 – 2 weeks
Maintenance is 1 g, 1 to 3 times/week
Conjugated estrogen cream (0.625 mg/g)
0.5–2 g/d for 21 days then off for 7 days
In practice during maintenance therapy, most women apply 1 – 3 times /week
Vaginal inserts (4-μg and 10-μg)
1 vaginal insert daily for 2 weeks
Maintenance is 1 insert twice weekly
SYNOPSIS:
Patients may experience vaginal atrophy as itching, dryness or pain during sexual activity. Vaginal estrogen has been shown to improve moderate to severe menopausal vaginal atrophy. Options for topical estrogen treatment are increasing. Women’s healthcare professionals need to confirm appropriate use of estrogen and help patients identify which treatment option will work best for their situation and lifestyle.
KEY POINTS:
During perimenopause and menopause, estrogen levels decline in vaginal tissues
Referred to as vulvovaginal atrophy (VVA), this may result in discomfort or pain during intercourse or general dryness and discomfort
If patient complains of dyspareunia, and clinical examination is consistent with postmenopausal vaginal atrophy / atrophic vaginitis, local estrogen is the first line and most effective treatment
Estrogen treatment may not be appropriate or desired by all patients
Ascertain if estrogen is an appropriate option for the patient
Screen for a history of breast or uterine cancer
History of blood clots
Liver conditions
If patient is appropriate for treatment with local estrogen, offering the spectrum of choices can help a patient identify the product that will work best for them
While there is a theoretical concern regarding systemic estrogen absorption and risk for uterine cancer, based on evidence, professional organizations consider “the addition of progestin for endometrial protection is not needed” (ACOG)
Differentiating factors include
Creams
Can be used on the vulva as well as internally in the vagina
Tablets or caplets
Some can be used during the day
Some tablets may need to be used at night because of the way they dissolve
Applicators
May be an issue of patient preference and warrants discussion
Ring
Benefits include ease of use
For some women, there may be structural issues related to comfort and/or retention (e.g., short or narrow vagina / prolapse)
Make patients aware that there are non-estrogen options available for use by women who are not appropriate candidates for local estrogen including
Prasterone | Ospemifene
Laser Treatments have been advocated as a possible treatment, however VVA not a currently FDA-approved indication
ACOG recommends that health care providers screen all women for a history of sexual assault. Screening should take place during routine wellness exams or when presented with symptoms that are suspicious for sexual assault (see ‘Red Flags’ below, in KEY POINTS).
The National Sexual Violence Resource Center recommends the following to further engage women in a discussion regarding sexual assault
Normalize the subject by including it within the sexual history; ACOG recommends the following introduction
“Because sexual violence is an enormous problem for women in this country and can affect a woman’s health and well-being, I now ask all my patients about exposure to violence and about sexual assault.”
Provide context by connecting the subject to the patient’s health and well-being
Be nonjudgmental
Validate the patient’s responses
Ask about sexual experiences that were uncomfortable or unwanted
Have you been touched without your consent?
Have you ever been pressured or forced to have sexual contact?
Do you feel that you have control over your sexual relationships?
SYNOPSIS:
Key findings of the National Intimate Partner and Sexual Violence Survey reveal that an estimated 1.3 million rape-related physical assaults occur against women annually. Early identification of victims can lead to prevention of long-term and persistent physical and mental health consequences of abuse.
KEY POINTS:
Decide on appropriate interventions depending on each individual situation
Pay particular attention to those who report pelvic pain, dysmenorrhea, or sexual dysfunction
Screening & Treatment of Gynecologic infections in the HIV-Positive Woman
Gynecologic infections are more common, and may be more difficult to eradicate, in the HIV population. Overall, treatment protocols remain the same, irrespective of HIV status, although there are some differences depending on the disorder.
CLINICAL ACTIONS:
Screen at entry to care and at least annually for the following: N.gonorrhoeae, C. trachomatis, syphilis and vaginal trichomoniasis
Screen for hepatitis C on entry to care
At-risk seronegative individuals should be screened at least annually
Consider type specific HSV serologic testing for those presenting for an STD evaluation
Approximately 70% of persons with HIV are HSV-2 seropositive | 95% are seropositive for either HSV-1 or HSV-2
HSV-2 infection increases the risk of HIV acquisition two- to three-fold and in coinfected patients
HSV-2 reactivation results in increases in HIV RNA levels in blood and genital secretions
Screen on entry to care for hepatitis B with HBsAg, anti-HBc and/or anti-HBs
Offer vaccination to seronegative individuals with hepatitis B or combined hepatitis A and B vaccine
Recheck immunity after vaccination complete
SYNOPSIS:
While it is critical to remain vigilant with regard to STDs and pelvic infections, women with ulcerative conditions of the genitalia, including syphilis and herpes, are at increased risk of HIV acquisition and transmission to partners, lending an urgency to prompt treatment or suppression (see separate entry on ulcerative conditions).
KEY POINTS:
Bacterial vaginosis is more prevalent/persistent in HIV-positive women
Diagnosis and treatment options are the same
Vulvovaginal candidiasis is more common among HIV-positive women and associated with decreased CD4+ counts
Treatment is the same as for HIV-negative women
For azole-refractory Candida glabrata vaginitis
Boric acid 600 mg vaginal suppository once daily for 14 days
Note: Severe or recurrent vaginitis should be treated with oral fluconazole (100 to 200 mg) or topical antifungals for ≥7 days
Treatment for gonorrhea/chlamydia is the same as for HIV-negative women
Retest 3 months after treatment as reinfection is common
Pelvic inflammatory disease is treated with the same antimicrobials for the same duration as for HIV-negative
There is a greater incidence of tubo-ovarian abscess among HIV-positive, but overall response to therapy is the same as for HIV-negative
Trichomoniasis is more prevalent among HIV-positive and should be treated with a one week course of metronidazole
Parasitic conditions such as scabies or pediculosis pubis are treated the same regardless of HIV status
Patient complaints regarding sexual functioning, either lowered levels of desire, or difficulty becoming aroused, are common. Currently, there are drugs, such as testosterone, that are being used ‘off label’ for this purpose. A patient may request a trial of a ‘more natural’ alternative, available over the counter (OTC) such as Dehydroepiandrosterone (DHEA). In this setting, consider discussing the following
Because DHEA converts into testosterone, ongoing use of DHEA may result in side effects associated with testosterone use
Side effects of DHEA are generally less severe than testosterone, although patients may experience some hair growth, oily skin or acne
In very high doses, more than 1600 milligrams daily, DHEA can have the same significant side effects as testosterone: hair growth, hair loss on the head, voice deepening and clitoral enlargement
SYNOPSIS:
Data support the positive role of androgens in female sexual function and ovarian physiology. However, the availability of approved testosterone formulations remains limited, particularly in the US. Therefore, patients may opt to obtain DHEA, the precursor hormone, in its stead. There is no positive guidance regarding the use of DHEA in women for sexual dysfunction because currently there remains a lack of well-designed studies demonstrating consistent clinical improvement.
KEY POINTS:
DHEA will convert into estrogen as well as testosterone and therefore extra caution to avoid this hormone may be reasonable in women with a history of breast or uterine cancer
DHEA is not FDA approved as a drug and therefore what is packaged may not be reliably indicated on the bottle
In a small but well-designed pilot study that studied sleep patterns in healthy postmenopausal women, DHEA supplementation can cause sleep stimulation or inhibition
ACOG states
Systemic DHEA has been tested but has not shown efficacy in postmenopausal women for treatment of sexual interest and arousal disorders and, therefore, is not recommended for use
Sex Education and the ObGyn: the ACOG Committee Opinion
CLINICAL ACTIONS
Comprehensive sexuality education should be medically accurate, evidence-based, and age-appropriate. Obstetrician-gynecologists can take part in this by addressing issues directly with adolescent patients in the following ways:
Participate locally in development of community programs on sexuality utilizing evidence-based curricula that focus on clear health goals (e.g. the prevention of pregnancy and STDs, including HIV)
Provide health care that focuses on optimizing sexual and reproductive health and development
Aid in designing programs that cover the variations in sexual expression, including vaginal intercourse, oral sex, anal sex, mutual masturbation, as well as texting and virtual sex
SYNOPSIS:
Community and school-based programs are an important facet of sexuality education. However, a preponderance of evidence suggests that when a responsible adult talks about sexual topics with adolescents, there is delayed sexual initiation and increased birth control and condom use. Although many parents talk with their adolescents about risks and responsibilities of sexual activity, one-third to one-half of females aged 15–19 years report never having talked with a parent about contraception, STDs, or “how to say no to sex.” The gynecologist can also play an important supporting role in this dialogue by open discussions with parents, guardians and adolescents.
KEY POINTS:
Sexuality education should be evidence-based and should include the benefits of delaying sexual intercourse, while also providing information about normal reproductive development, contraception (including long-acting reversible contraception methods) to prevent unintended pregnancies, as well as barrier protection to prevent STDs
Sex education should be tailored to specific ethnicities and cultural groups and should be inclusive of those with physical, and cognitive disabilities
Sex education should not marginalize lesbian, gay, bisexual, questioning, and transgender individuals and those that have variations in sexual development
Studies have demonstrated that comprehensive sexuality education programs reduce the rates of sexual activity, sexual risk behaviors (e.g. number of partners and unprotected intercourse, STDs, and adolescent pregnancy)
Obstetrician–gynecologists have the unique opportunity to act “bi-generationally” by asking their patients about their adolescents’ reproductive development and sexual education, human papillomavirus vaccination status, and contraceptive needs
Inquire about patient’s use of lubricants if/when the patient expresses any discomfort with intercourse
Address misconceptions by educating women about lubricant basics and encourage women to try various lubricants until they find the one that works best for them
If a patient is currently using a lubricant during intercourse, it is likely that any experienced pain is due to causes other than vaginal dryness
SYNOPSIS:
Use of lubricants can be essential for allowing sexual intercourse to be pleasurable. Given the array of available options on the market, as well as numerous misconceptions regarding lubricants, women often find it helpful when providers educate them about available options and make recommendations. It is important to reassure women, especially young women, that the use of lubricants should not be considered shameful in any way, and that the need for lubricants is dependent on many physiological factors that are not age related.
KEY POINTS:
There are significant differences between lubricants, and there is no “one-size-fits-all” product
The “classic” lubricants, those which are most ubiquitous and often most popular due to effective advertising, are not necessarily the most effective
Lubricants are either water-based or silicone-based and differ significantly from each other
Silicone based lubricants last longer, feel silkier and can be used in water, but should not be used with silicone toys
Water based lubricants are experienced as “slicker and thinner”, dry up faster and are easier to clean
Textures vary from watery to more viscous, or “tacky”
Most women prefer those that remain more fluid for a longer time; however, each woman should try various options to determine what feels best for her and her partner
Pure coconut oil is a popular, effective and natural lubricant that is easily available
If patients are prone to yeast infections, they should avoid glycerin-based lubricants; this includes all flavored lubricants
Petroleum jelly (vaseline) should never be used as a lubricant
Lubricants should be used on partner’s penis, as well as on the vulva or intravaginally
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer
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presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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