Treatment of Postmenopausal Genitourinary Syndrome

First-Line Treatments

Vaginal estrogen therapy is considered the gold standard treatment for genitourinary syndrome of menopause (GSM) due to its direct effect on epithelial regeneration and anti-inflammatory properties, effectively treating vaginal dryness, dyspareunia, and relieving urogenital symptoms related to vaginal atrophy, with minimal systemic absorption through atrophic mucosa, making it safer than systemic hormone therapy, according to the American College of Obstetricians and Gynecologists 1
Vaginal estrogen therapy is available in multiple formulations, including creams, rings, and suppositories, as recommended by the National Comprehensive Cancer Network 3
The American College of Obstetricians and Gynecologists recommends vaginal estrogen therapy as the most effective first-line treatment for postmenopausal genitourinary syndrome, with ospemifene being an effective alternative for women with contraindications to estrogen therapy, as supported by evidence from Radiologia Medica and Annals of Oncology 1, 2

Vaginal moisturizers and lubricants are considered a first-line non-hormonal option for women with contraindications to hormonal therapy, with regular use hydrating vaginal mucosa and minimizing dryness and pain during sexual activity, as recommended by the North American Menopause Society 5, 1
Topical application of hyaluronic acid with vitamins E and A can prevent acute and late vaginal toxicities, support cellular differentiation, keratinocyte proliferation, and the extracellular matrix of vaginal epithelium, and reduce dyspareunia, vaginal mucosal inflammation, dryness, bleeding, fibrosis, and cellular atypia, according to the European Menopause and Andropause Society 5

The National Comprehensive Cancer Network recommends that ospemifene may be considered for dyspareunia in survivors without a history of estrogen-dependent cancers, with caution, due to the potential increased risk of endometrial cancer 4
Low-dose intravaginal estrogens may be considered to manage genitourinary symptoms in breast cancer survivors, but with caution, as recommended by the European Society for Medical Oncology 2
Local vaginal estrogen preparations have minimal systemic absorption and generally don't require concurrent progestin, according to the American College of Obstetricians and Gynecologists 1

The initial assessment should evaluate the severity of symptoms, including vaginal dryness, dyspareunia, and urinary symptoms, and review medical history for contraindications to hormonal therapy, as recommended by the National Comprehensive Cancer Network and the American College of Obstetricians and Gynecologists 2, 6, 3
First-line treatment options include low-dose vaginal estrogen for women without contraindications, and ospemifene or non-hormonal moisturizers/lubricants for women with contraindications to estrogen, as recommended by the National Comprehensive Cancer Network and the American College of Obstetricians and Gynecologists 1, 4