Management of Genitourinary Syndrome of Menopause

Non-Hormonal Treatments

Non-hormonal moisturizers, such as Replens or Sylk, are recommended as first-line treatment for managing vaginal dryness in women who cannot or prefer not to use hormonal treatments, and can improve vulvovaginal tissue quality and alleviate symptoms when applied 3-5 times weekly 1, 2
Lubricants, either water or silicone-based, should be used for sexual activity to alleviate vaginal dryness, according to the National Comprehensive Cancer Network 3
Topical vitamin D or E may help alleviate symptoms of vaginal dryness, as suggested by the National Comprehensive Cancer Network 2
Pelvic floor physical therapy can improve sexual pain, arousal, lubrication, and orgasm, as recommended by the National Comprehensive Cancer Network 2
Vaginal dilators can be helpful for vaginal stenosis or pain during sexual activity, especially for survivors of pelvic radiation, according to the National Comprehensive Cancer Network 2

For women without contraindications to hormonal therapy, low-dose vaginal estrogen (creams, tablets, rings) or vaginal DHEA (prasterone) may be considered, but women on aromatase inhibitors should be cautious with hormonal treatments 1, 2
Estriol-containing preparations may be considered instead of estradiol for women with a history of estrogen-dependent cancers who require vaginal estrogen therapy, and may be preferable for women on aromatase inhibitors, as estriol cannot be converted to estradiol 1
Vaginal estrogen creams, containing estradiol or conjugated equine estrogen, can be applied directly to vaginal tissues, as recommended by the American College of Obstetricians and Gynecologists 1
Vaginal estrogen tablets, low-dose estradiol tablets inserted vaginally, have similar efficacy to creams with potentially fewer side effects, according to the American College of Obstetricians and Gynecologists 1
Estradiol-releasing vaginal rings deliver continuous low-dose estradiol over 90 days and are preferred by many women for ease of use and comfort, as recommended by the North American Menopause Society 1
DHEA vaginal suppositories (prasterone) can improve sexual desire, arousal, pain, and overall sexual function, but should be used with caution in patients on aromatase inhibitors, as recommended by the National Comprehensive Cancer Network 2

Response to treatment with non-hormonal moisturizers like Replens should be evaluated after 4-6 weeks, and if symptoms persist, consideration should be given to increasing the frequency of application or adding lubricants specifically for sexual activity 2
Evaluate response to treatment after 4-6 weeks and use the lowest effective dose for the shortest duration needed, as recommended by the National Comprehensive Cancer Network 4
Vaginal estradiol may increase circulating estradiol levels within 2 weeks of use in women on aromatase inhibitors, as warned by the American College of Obstetricians and Gynecologists 1

Vaginal laser therapy has not been cleared or approved by the FDA for treating menopausal symptoms due to lack of established safety and effectiveness, and additional studies are needed before this type of treatment can be recommended 2
Ospemifene (SERM) is an oral medication for treating dyspareunia, but is contraindicated in women with a history of breast cancer, according to the National Comprehensive Cancer Network 2 and the American College of Clinical Oncology 5
Transdermal estrogen formulations may be preferred over oral due to lower rates of venous thromboembolism and stroke, as recommended by the National Comprehensive Cancer Network 3