Alternative Treatments for Patients Previously Using Estradiol Cream

First-Line Non-Hormonal Options

Vaginal moisturizers should be applied frequently for daily comfort in the vagina, at the vaginal opening, and on external vulvar folds, as recommended by the American College of Obstetricians and Gynecologists 3, 2
Water-based or silicone-based lubricants should be used during sexual activity to reduce friction and discomfort, according to the American College of Obstetricians and Gynecologists 3, 2
Non-hormonal options should be tried thoroughly before considering hormonal alternatives, as suggested by the American College of Obstetricians and Gynecologists 3
These options provide temporary relief but may be less effective than topical estrogens for persistent symptoms, as noted by the American College of Obstetricians and Gynecologists 3

Vaginal DHEA (prasterone) is an effective option for women with vaginal atrophy symptoms and can be used even in patients with a history of breast cancer on aromatase inhibitors, as recommended by the American Society of Clinical Oncology 1, 3
Ospemifene, a selective estrogen receptor modulator, can be offered to postmenopausal women without current or history of breast cancer who are experiencing dyspareunia and vaginal atrophy, according to the American Society of Clinical Oncology 1, 2
Low-dose vaginal estradiol tablets may be considered if available, as suggested by the European Society for Medical Oncology 4

For women with hormone-positive breast cancer who are symptomatic and not responding to conservative measures, low-dose vaginal estrogen can be considered after a thorough discussion of risks and benefits, as recommended by the American Society of Clinical Oncology 1, 3
For patients on aromatase inhibitors, vaginal DHEA is preferred over estradiol-containing preparations to avoid potential interference with AI efficacy, according to the American Society of Clinical Oncology 3
Lidocaine can be offered for persistent introital pain and dyspareunia in breast cancer patients, as suggested by the American Society of Clinical Oncology 1, 3

Vaginal dilators may benefit patients with vaginismus or vaginal stenosis, particularly important for those treated with pelvic radiation therapy, as recommended by the American Society of Clinical Oncology 1, 3
Cognitive behavioral therapy and pelvic floor exercises may help decrease anxiety, discomfort, and lower urinary tract symptoms, according to the American Society of Clinical Oncology 1, 3
Pelvic floor physiotherapy should be offered to women with pain or other pelvic floor issues, as suggested by the American Society of Clinical Oncology 1

For women requiring contraception, non-hormonal methods such as copper IUDs should be considered, as recommended by the American Heart Association 5, 6
Levonorgestrel-releasing IUDs may be appropriate for some patients, providing both contraception and potential relief of vaginal symptoms, according to the American College of Rheumatology 6
Women with positive antiphospholipid antibodies should avoid estrogen-containing contraceptives due to increased thrombosis risk, as noted by the American College of Rheumatology 6