Vulvovaginal atrophy

Specialty: Gynecology and breast.

• Postmenopausal vaginal dryness
• genitourinary syndrome of menopause
• senile vaginitis

Why it occurs

• Physiological postmenopausal estrogen deprivation
• Iatrogenic hypoestrogenism (secondary to bilateral oophorectomy, chemotherapy, pelvic radiotherapy or use of GnRH agonists)
• Prolonged breastfeeding (due to high prolactin levels and temporary estrogen suppression)
• Use of antiestrogens (such as tamoxifen or aromatase inhibitors in the treatment of breast cancer)

Initial workup

Vaginal physical examination (pale, smooth mucosa is observed, without vaginal folds, with petechiae or diffuse erythema, and a high vaginal pH greater than 5.0). Vaginal cytology to assess the cellular maturation index (predominance of parabasal over superficial cells). Culture of secretions to rule out vaginismus or associated infectious vaginitis.

Standard management

• Estriol vaginal cream 0.1% or estradiol vaginal tablets 10 micrograms — apply daily for 2 weeks, then twice a week as continued maintenance
• Ospemifene 60 mg orally daily — selective estrogen receptor modulator with vaginal agonist action, alternative of choice if non-local treatments are preferred
• Vaginal moisturizers based on hyaluronic acid applied 2-3 times a week associated with water-based lubricants during intercourse (note: treatment with local topical estrogens at low doses is safe and effective in the majority of patients without a history of hormone-dependent cancer).