Vaginal Lubricants and Moisturizers

Lubricants and moisturizers are nonprescription therapies that can be used by women who choose not to use vaginal estrogen therapy to address dyspareunia in menopause.9 Lubricants provide short-term relief of vaginal dryness associated with dyspareunia.8 They come in water-, silicone-, or oil-based formulations. Each can be applied to the vulva or vagina (or both) before sexual activity.8 Water-based lubricants are preferred over silicone-based formulations due to their nonstaining properties and lower incidence of genital symptoms.9 Examples of lubricants include YES®, JO®, Good Clean Love, Pink®, and überlube. Vaginal moisturizers can be used daily to maintain vaginal moisture.8 They provide longer-term relief than lubricants by increasing mucosal moisture and reducing pH.9 Examples of moisturizers include ReplensTM, RepHreshTM, Satin by Sliquid®, and Hyalo Gyn®.8 Vaginal lubricants and moisturizers can be used as needed in combination with prescription therapy options.

Topical Estrogen


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Dyspareunia in menopause can often be treated with low-dose topical estrogen applied directly to the vagina. It is the preferred prescription treatment for vaginal dryness associated with dyspareunia that is unresponsive to nonprescription therapies.10 With low-dose vaginal estrogen therapy, systemic estrogen absorption is minimal.10 Multiple vaginal estrogen products with comparable efficacy are approved by the U.S. Food and Drug Administration (FDA). Selection should be mainly based on patient preference and comprehensive medical history.10 Some topical estrogen products are available as vaginal creams and vaginal tablets.10 Estrogen in these forms provides a soothing and moisturizing effect to the vagina.10 Examples of vaginal estrogen creams include estradiol-17β and conjugated estrogens. Estradiol hemihydrate is an example of a vaginal insert. Topical estrogen creams and vaginal tablets are typically prescribed daily for the first 2 weeks, then twice weekly for maintenance dosing.10 It is important to note that women should be on the lowest dose of estrogen for the shortest duration of time.

Selective Estrogen Receptor Modulators

Selective estrogen receptor modulators are synthetic nonsteroidal agents that exert variable mixed estrogen agonist and antagonist effects on target tissues.11 In 2013, the FDA approved ospemifene for the treatment of moderate to severe postmenopausal dyspareunia. Ospemifene is a unique drug in this class that increases vaginal epithelial cells and decreases vaginal pH.12 It acts like estrogen on the vaginal lining but does not appear to have estrogen’s potentially harmful effects on breast tissue. However, studies have yet to confirm the safety of this medication in women at high risk for breast cancer.8 Adverse effects may include hot flashes, and the drug increases risk for stroke, blood clots, and endometrial cancer.8 Ospemifene is prescribed as 60 mg/d orally.11 It may be a good option for women who are opposed to or unable to use estrogen.

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Vaginal Dehydroepiandrosterone

Prasterone is a medication containing DHEA, an endogenous steroid prohormone that is part of the biosynthetic pathway that results in the production of testosterone and estradiol.3 It is dispensed as a 6.5-mg capsule that is inserted into the vagina daily.8 Clinical trials with daily use of prasterone have shown improvements in dyspareunia.13,14 Prasterone is believed to exert its effect by facilitating conversion of DHEA to testosterone and estradiol.14 Studies have shown that it does not increase systemic steroid hormone levels because of local inactivation.14,15 As a result, it may be a safer alternative to vaginal estrogen therapies in patients with contraindications to estrogen use.8

Patient Counseling

Healthcare providers should provide adequate education to menopausal women undergoing evaluation for dyspareunia. Patient education is essential so that women learn about the vaginal changes that occur with the decrease in estrogen during menopause that may result in dyspareunia.8 Patients should be advised that dyspareunia is unlikely to improve without treatment.8 Counseling should include a review of both hormonal and non-hormonal treatment options.8 Patients should be instructed when to follow up with healthcare providers, which typically occurs 2 to 4 months after initiating treatment. Written information and instructions should be given to reinforce the treatment plan and support patient adherence.

Credible educational resources on menopause and dyspareunia are available for patients. Clinicians can direct patients to the North American Menopause Society, the American College of Obstetricians and Gynecologists, and the American Sexual Health Association for further information.

References

  1. Casanova R, Chuang A, Goepfert AR, et al. Beckmann and Lings Obstetrics and Gynecology. Philadelphia: Wolters Kluwer; 2019.
  2. Castelo-Branco C, Cancelo MJ, Villero J, Nohales F, Julia MD. Management of post-menopausal vaginal atrophy and atrophic vaginitis. Maturitas. 2005;52(Suppl 1):S46-S52.
  3. Seehusen DA, Baird DC, Bode DV. Dyspareunia in women. Am Fam Physician. 2014;90(7):465-470.
  4. Scemons D, Egan T. Improving care for one in five women: evaluating and managing dyspareunia. Available at: https://www.gavinpublishers.com/articles/Review-Article/International-Journal-of-Nursing-and-Health-Care-Research/Improving-Care-for-One-in-Five-Women-Evaluating-and-Managing-Dyspareunia. Accessed March 4, 2019.
  5. Pazmany E, Bergeron S, Verhaeghe J, Van Oudenhove L, Enzlin P. Sexual communication, dyadic adjustment, and psychosexual well‐being in premenopausal women with self‐reported dyspareunia and their partners: a controlled study. J Sex Med. 2014;11(7):1786-1797.
  6. Coady D. Chronic sexual pain: a layered guide to evaluation. Available at: https://www.contemporaryobgyn.net/endometriosis/chronic-sexual-pain-layered-guide-evaluation. Published August 12, 2015. Accessed March 15, 2019.
  7. Portman DJ, Gass MLS; Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Menopause. 2014;21(10):1063-1068.
  8. Faubion SS, Sood R, Kapoor E. Genitourinary syndrome of menopause: management strategies for the clinician. Mayo Clin Proc. 2017;92(12):1842-1849.
  9. Edwards D, Panay N. Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition? Climacteric. 2016;19(2):151-161.
  10. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause. 2013;20(9):888-902.
  11. Portman DJ, Bachmann GA, Simon JA; Ospemifene Study Group. Ospemifene, a novel selective estrogen receptor modulator for treating dyspareunia associated with postmenopausal vulvar and vaginal atrophy. Menopause.  2013;20(6):623-630.
  12. Soe LH, Wurz GT, Kao CJ, DeGregorio MW. Ospemifene for the treatment of dyspareunia associated with vulvar and vaginal atrophy: potential benefits in bone and breast. Int J Women’s Health. 2013;5:605-611.
  13. Portman DJ, Labrie F, Archer DF, et al; other participating members of VVA Prasterone Group. Lack of effect of intravaginal dehydroepiandrosterone (DHEA, prasterone) on the endometrium in postmenopausal women. Menopause. 2015;22(12):1289-1295.
  14. Labrie F, Archer DF, Bouchard C, et al. Intravaginal dehydroepiandrosterone (prasterone), a highly efficient treatment of dyspareunia. Climacteric. 2011;14(2):282-288.
  15. Labrie F, Archer DF, Koltun W, et al; VVA Prasterone Research Group. Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. Menopause. 2016;23(3):243-256.