Treatment of Vaginal Dryness

First-Line: Non-Hormonal Topical Therapy

The American College of Obstetricians and Gynecologists recommends vaginal moisturizers as the foundation of treatment, applied 3-5 times per week to the vagina, vaginal opening, and external vulvar folds for optimal symptom control 1, 3
Vaginal moisturizers provide daily maintenance of vaginal tissue health and can be as effective as low-dose estrogen for mild to moderate symptoms 1, 2
Water-based lubricants reduce friction and discomfort during intercourse, while silicone-based lubricants last longer and may provide more effective relief 1, 2, 3
Additional topical options include vitamin D or E applied topically for supplementary symptom relief, and topical lidocaine applied to the vulvar vestibule before penetration for persistent introital pain 1, 2, 3

Pelvic floor physical therapy significantly improves sexual pain, arousal, lubrication, orgasm, and overall satisfaction, and should be considered early, particularly when pain is a prominent feature 1, 2, 3
Vaginal dilators benefit women with vaginismus, vaginal stenosis, or pain during sexual activity, particularly those treated with pelvic radiation, and are recommended by the National Comprehensive Cancer Network for managing dyspareunia 1, 2, 3
Cognitive behavioral therapy may decrease anxiety and discomfort related to sexual activity and improve overall sexual functioning 1, 3

Vaginal DHEA is FDA-approved for vaginal dryness and dyspareunia, improving sexual desire, arousal, pain, and overall sexual function, and is particularly useful for women on aromatase inhibitors who have not responded to non-hormonal treatments 1, 2, 3
Ospemifene 60 mg daily is FDA-approved for moderate to severe dyspareunia and vaginal dryness in postmenopausal women, with statistically significant improvements in dyspareunia and vaginal dryness compared to placebo 1, 3
Vaginal estrogen is the most effective treatment when non-hormonal options fail, with low-dose formulations minimizing systemic absorption while effectively treating symptoms 2, 3, 4, 5

For women with hormone-positive breast cancer, non-hormonal options must be tried first before considering any hormonal therapy 1, 2, 3
Women on aromatase inhibitors should generally avoid vaginal estrogen as it may increase circulating estradiol within 2 weeks of use and potentially reverse the efficacy of aromatase inhibitor therapy, and vaginal DHEA is the preferred hormonal option for these patients who haven't responded to non-hormonal treatments 1, 2, 4, 5
If vaginal estrogens must be used in breast cancer survivors, estriol-containing preparations may be preferable as estriol is a weaker estrogen that cannot be converted to estradiol 2, 4, 5