Atrophic Vaginitis (Genitourinary Syndrome of Menopause): Treatment Options

Pharmacy and Therapeutics

“It is reasonable to try nonhormonal therapy as a first-line option to alleviate vulvovaginal symptoms caused by genitourinary syndrome of menopause. Although not as effective as estrogen, vaginal moisturizers, such as Replens, are an effective treatment for mild vaginal dryness and related dyspareunia.” AFP 2016

  1. Premarin (conjugated estrogen) vaginal cream. 0.625 mg of conjugated equine estrogen per gram. Rx: 0.5-2 g PV 1-3 times / wk.  Start: 0.5 to 2 g PV QD x 2 wk, then taper dose gradually to maintenance. Alt: 0.5-2 g PV QD x 3wk, off x 1wk, then repeat.
  2. Estrace (estradiol) vaginal cream 0.01%. Rx: 1g PV 1-3 times / wk. Start: 2 to 4 g PV QD x 2wks, then taper dose to 1g 1-3 times per wk for maintenance treatment.
  3. Estring (estradiol) vaginal ring. 2 mg released at 7.5 mcg per day over three months.
  4. Vagifem (estradiol) vaginal tablet. 10 mcg applied once daily for two weeks, then twice weekly.
  5. Replens vaginal moisturizer. Applied three times per week. [Non-hormonal]
  6. Osphena (ospemifene) 60 mg per day taken orally with food. [Don’t give to patients w/ hx of breast cancer or DVT. S/e is hot flashes.]

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“Women using low-dose vaginal estrogen for less than one year should not require a progestogen to decrease the risk of endometrial cancer, but there are no long-term data.”

Will consider an endometrial biopsy and/or transvaginal ultrasonography if spotting or bleeding occurs while using low-dose vaginal estrogen.

Will refer patients with a history of hormone-dependent cancers to Gynecology when they require the use vaginal estrogen formulations.

There is no evidence that using low-dose local estrogen increases the risk of breast cancer recurrence.”

Estrace (Estradiol) vaginal cream preferred when inflammation, very atrophic, dry, cracks are present because Premarin causes burning when the patient applies it.

Premarin = the name comes from Pregnant Mare (female horse) Urine. That’s where Premarin comes from.

Premarin consists of conjugated equine estrogens (CEEs), or, more exactly, the sodium salts of the sulfate esters of equine estrogens. The non-estrogen component causes burning pain when patients with atrophic vaginitis use it. As such, they would often stop using it. To solve that, prescribe Estrace instead of Premarin when the inflammation is significant.

 

Reference

Am Fam Physician. 2016 Dec 1;94(11):884-889. http://www.aafp.org/afp/2016/1201/p884.html

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