madman
Super Moderator
ABSTRACT
Introduction
Vulvovaginal atrophy (VVA) predominantly affects postmenopausal women due to hormonal decline but can also occur in premenopausal women with conditions such as primary ovarian insufficiency or exposure to anti-estrogen medications. Contributing factors include smoking and certain medical treatments. Symptoms like dyspareunia and loss of sexual function affect many women but are underreported due to stigma and lack of awareness. Current treatments range from over-the-counter lubricants to hormonal therapies like estrogen receptor agonists, which improve vaginal elasticity and moisture with minimal systemic absorption.
Areas covered
This review evaluates current and emerging estrogen receptor agonists for VVA treatment. A comprehensive search was conducted using PubMed between August and September 2024, supplemented by snowball sampling from key references.
Expert opinion
Despite its prevalence, VVA remains underdiagnosed, with increasing recognition due to longer lifespans and focus on quality of life. Diagnosis involves comprehensive symptom assessment, including sexual history, urinary tract infection frequency, and clinical exams, with vaginal pH measurements and smear microscopy to determine the condition’s severity. Treatment usually involves estrogen, but not all women can safely use it, and preferences toward estrogen must be respected. Alternatives like selective estrogen receptor modulators (SERMs) such as prasterone and ospemifene show promise but need more long-term safety data. Emerging options like E3 and E4 demonstrate efficacy and safety in low doses. Future treatments will emphasize convenience and adherence, making timely diagnosis and management of VVA routine in women’s health care.
3. Treatment with current and emerging estrogen receptor agonists
In the treatment of vulvovaginal atrophy with estrogen receptor agonists, we can differentiate local and systemic treatments (Table 1). Local treatments contain limited doses of estrogen distributed directly into the vaginal, mainly addressing local symptoms. Systematic therapy commonly contains higher doses of estrogens enabling systematic action and may cause endometrial hyperplasia and breast tissue activation [10].
3.1. Estrone (E1)
3.2. Estradiol (E2)
3.3. Estriol (E3)
3.4. Estetrol (E4)
3.5. Ospemifene
3.6. Dehydroepiandrosterone (DHEA)
4. Conclusion
Several safe and effective therapies are available for the treatment of VVA, both hormonal and non-hormonal. The cornerstone of treatment is intravaginal estrogen therapy, which is highly effective and safe when administered at the lowest possible dose directly in the vagina. For women with contraindications to estrogen, or those preferring non-hormonal options, alternatives such as non-hormonal moisturizers can be effective if symptoms are limited to vaginal dryness or discomfort during intercourse. In cases involving sexual dysfunction, additional benefits may be achieved with intravaginal androgens like DHEA or oral ospemifene, although the latter is more expensive and not widely covered by insurance. Also, larger, longer-term studies would be valuable to confirm the safety of these treatments with estrogen receptor agonists for VVA, especially on breast and endometrium. For women,unable to use systemic estrogen, like in breast cancer patients, ultra-low dose estriol, potentially combined with probiotic lactobacilli, offers a safe and effective alternative.
Introduction
Vulvovaginal atrophy (VVA) predominantly affects postmenopausal women due to hormonal decline but can also occur in premenopausal women with conditions such as primary ovarian insufficiency or exposure to anti-estrogen medications. Contributing factors include smoking and certain medical treatments. Symptoms like dyspareunia and loss of sexual function affect many women but are underreported due to stigma and lack of awareness. Current treatments range from over-the-counter lubricants to hormonal therapies like estrogen receptor agonists, which improve vaginal elasticity and moisture with minimal systemic absorption.
Areas covered
This review evaluates current and emerging estrogen receptor agonists for VVA treatment. A comprehensive search was conducted using PubMed between August and September 2024, supplemented by snowball sampling from key references.
Expert opinion
Despite its prevalence, VVA remains underdiagnosed, with increasing recognition due to longer lifespans and focus on quality of life. Diagnosis involves comprehensive symptom assessment, including sexual history, urinary tract infection frequency, and clinical exams, with vaginal pH measurements and smear microscopy to determine the condition’s severity. Treatment usually involves estrogen, but not all women can safely use it, and preferences toward estrogen must be respected. Alternatives like selective estrogen receptor modulators (SERMs) such as prasterone and ospemifene show promise but need more long-term safety data. Emerging options like E3 and E4 demonstrate efficacy and safety in low doses. Future treatments will emphasize convenience and adherence, making timely diagnosis and management of VVA routine in women’s health care.
3. Treatment with current and emerging estrogen receptor agonists
In the treatment of vulvovaginal atrophy with estrogen receptor agonists, we can differentiate local and systemic treatments (Table 1). Local treatments contain limited doses of estrogen distributed directly into the vaginal, mainly addressing local symptoms. Systematic therapy commonly contains higher doses of estrogens enabling systematic action and may cause endometrial hyperplasia and breast tissue activation [10].
3.1. Estrone (E1)
3.2. Estradiol (E2)
3.3. Estriol (E3)
3.4. Estetrol (E4)
3.5. Ospemifene
3.6. Dehydroepiandrosterone (DHEA)
4. Conclusion
Several safe and effective therapies are available for the treatment of VVA, both hormonal and non-hormonal. The cornerstone of treatment is intravaginal estrogen therapy, which is highly effective and safe when administered at the lowest possible dose directly in the vagina. For women with contraindications to estrogen, or those preferring non-hormonal options, alternatives such as non-hormonal moisturizers can be effective if symptoms are limited to vaginal dryness or discomfort during intercourse. In cases involving sexual dysfunction, additional benefits may be achieved with intravaginal androgens like DHEA or oral ospemifene, although the latter is more expensive and not widely covered by insurance. Also, larger, longer-term studies would be valuable to confirm the safety of these treatments with estrogen receptor agonists for VVA, especially on breast and endometrium. For women,unable to use systemic estrogen, like in breast cancer patients, ultra-low dose estriol, potentially combined with probiotic lactobacilli, offers a safe and effective alternative.
