Advances in the Treatment of Vulvovaginal Atrophy

Jill M Krapf; Zoe R Belkin; Andrew T Goldstein


Expert Rev of Obstet Gynecol. 2013;8(5):457-465. 

In This Article

Nonhormonal Treatment Options

In seeking out relief, sufferers from vulvovaginal atrophy often initially try over-the-counter vaginal lubricants and moisturizers. These nonhormonal options primarily focus on relieving symptoms of vaginal dryness and dyspareunia. More specifically, vaginal lubricants are designed to reduce friction associated with sexual activity, whereas vaginal moisturizers are utilized as maintenance therapy to replace normal vaginal secretions.[50,51] A few small prospective studies analyzed the efficacy of the commonly used vaginal moisturizer, Replens.[101] This polycarbophil-based vaginal moisturizer was to improve vaginal moisture and elasticity thereby reducing symptoms of itching, irritation and dyspareunia.[52,53] In addition, cytological studies indicated a positive effect on maturation of the vaginal epithelium.[54] A Phase II randomized double-blind study showed that both Replens and a placebo lubricating product decreased vaginal dryness and dyspareunia in women with breast cancer, with most benefit occurring in the first two weeks of treatment.[55] Currently available vaginal moisturizers and lubricants may be a viable alternative for relief of vaginal dryness in women with a contraindication to estrogen use.

HA, a biopolymer that releases water molecules into tissue, may be compounded into a vaginal gel. HA vaginal gel allows for hydration and repair of the vagina without irritating the vaginal mucosa. In a randomized study of 42 postmenopausal women with atrophic vaginitis, treatment with either HA (5 mg) or estradiol (25 μg vaginal tablet) provided symptom relief, decreased vaginal pH and increased maturation of the vaginal epithelium. However, these improvements were greater for the estradiol than the HA group.[56] In a multicenter, controlled, open-label, parallel-group clinical trial, 144 postmenopausal women with vaginal dryness were randomized to receive HA vaginal gel or estriol cream which they applied vaginally once every 3 days for a total of 10 applications over 30 days. This was an inferiority study, which had no placebo group. Both the HA vaginal gel and estriol cream groups showed significant improvement in clinical symptoms of vaginal dryness, itching, burning and dyspareunia. Unlike the estrogen control group, there was no improvement in vaginal pH for the women using HA. Eighty percent of the HA and 77% of the estriol cream group exhibited no change in vaginal microenvironment before and after application. The vaginal microecosystem became normal for 10% of the HA group and 21% of the estriol cream group. These results suggest that estriol cream had a therapeutic effect, promoting synthesis of epithelial glycogen and growth of lactobacilli, while HA vaginal gel did not display a therapeutic effect on vaginal mucosa.[57]

Widely available vaginal pH-balanced gels, containing lactic acid to promote a pH of 4.0, have also been studied as a nonhormonal alternative for treatment of vaginal atrophy among breast cancer survivors. A randomized, double-blind, placebo-controlled study of 86 chemotherapy or endocrine-therapy-induced menopausal breast cancer survivors received pH-balanced vaginal gel or placebo 3 times per week for 12 weeks. There was a significant improvement in vaginal dryness, dyspareunia, pH and VMI in the treatment group as compared to the placebo group. The most common side effects of the pH-balanced gels were vaginal irritation and sensation of burning.[58]