Management of Postmenopausal Vaginal Dryness

Treatment Options

• Non-hormonal, water-based lubricants and moisturizers should be offered as the primary treatment for postmenopausal vaginal dryness, as recommended by the American Cancer Society and American Society of Clinical Oncology 1, 2, 3
• Silicone-based products may last longer than water-based or glycerin-based products 1
• A combination of lubricants and moisturizers may provide additional short-term comfort 1
• Results from estrogen therapy typically take 6-12 weeks to become noticeable, although it is contraindicated in certain hormone-sensitive cancers, as recommended by the American Society for Reproductive Medicine and the American Cancer Society 1, 2, 4
• Hormonal therapies such as low-dose estrogen vaginal tablets are not recommended for women on aromatase inhibitors, and the safety of vaginal estrogen in women with a history of breast cancer is not well established 1
• Vaginal DHEA (prasterone) may be suitable for women who cannot use estrogen, although it is contraindicated in women with a history of breast cancer, as reported by the International Society for the Study of Women's Sexual Health 5, 6
• Topical vitamins, such as vitamin D or E, may be used to alleviate vaginal dryness and discomfort, particularly for symptoms of burning in the vagina, as suggested by the American College of Obstetricians and Gynecologists 7, 8, 5

Treatment Frequencies and Durations

9, 10

Contraindications for Hormone Therapy

• Pregnancy is an absolute contraindication for hormone therapy due to the risk of fetal virilization in women and potential adverse outcomes, as recommended by the American College of Obstetricians and Gynecologists 11
• Severe liver disease is an absolute contraindication for hormone therapy, increasing the risk of adverse outcomes, as recommended by the American Association for the Study of Liver Diseases 11
• Active cardiovascular disease is a contraindication for testosterone therapy, increasing the risk of adverse outcomes, according to the American Heart Association 12
• Estrogen therapy is contraindicated in patients with advanced endometrioid uterine adenocarcinoma, and in women with known or suspected estrogen-dependent neoplasia, undiagnosed abnormal genital bleeding, or active thromboembolic disorders 13, 14, 4

Ongoing Care and Monitoring

• Consider referral for psychoeducational support, sexual counseling, or marital counseling for persistent sexual complaints, as recommended by the National Comprehensive Cancer Network 1, 9
• Regular follow-up is necessary to assess symptom improvement and monitor for any abnormal vaginal bleeding, which would warrant further investigation, as recommended by the American College of Obstetricians and Gynecologists 15
• Annual clinical review is essential to assess ongoing need and compliance, according to the National Comprehensive Cancer Network 3
• Patients should be monitored for local side effects, such as irritation and spotting, and discuss risks and benefits with their healthcare team before initiation, especially for women with a history of estrogen-related malignancies 13

Urinary Incontinence Management

• Pelvic floor muscle training combined with vaginal estrogen formulations is recommended as first-line treatment for women with stress urinary incontinence and vaginal atrophy, with significant improvement in both conditions and minimal side effects, as recommended by the American College of Physicians 16
• Pelvic floor muscle training is a strong recommendation as first-line treatment for stress incontinence, and should be taught and supervised by a healthcare professional, with adequate instruction and supervision being crucial for its effectiveness 16, 17
• Pelvic floor muscle training plus bladder training is recommended for mixed incontinence, as suggested by the American College of Physicians 16
• Weight loss is particularly effective for stress incontinence in women who are overweight or obese, with a target of a structured weight loss program, as recommended by the American College of Physicians 17
• A continence pessary is an alternative for women who cannot perform pelvic floor muscle training or prefer a device-based approach, as suggested by the American Urological Association 18
• Surgical options, such as mid-urethral synthetic sling, autologous fascia pubovaginal sling, Burch colposuspension, and urethral bulking agents, are available for predominant stress incontinence, as recommended by the American Urological Association 18