Non-estrogen based treatments for vaginal atrophy

Abstract

Vulvovaginal atrophy (VVA), or Genitourinary Syndrome of Menopause (GSM) is a common condition of menopausal women. The burning, itching, dryness, irritation, and dyspareunia of GSM are progressive. Prescription therapies have focused on “estrogen”, here, we review the nonhormonal options. For many women over-the-counter moisturizers and lubricants are effective in relieving symptoms or are used as in combination with pharmaceutical preparations. Vaginal moisturizers are primarily hydrophilic compounds which bind to the vaginal wall and draw moisture into the vagina. They lower vaginal pH, eliminate cellular debris, and increase vaginal fluid. Moisturizers can improve vaginal itching, irritation, and dyspareunia. They are used independent of sexual activity. Lubricants are used with sexual activity and fall into four types: water soluble, silicone polymers, oils and hybrids. Lubricants decrease vaginal irritation during sexual activity, there is limited evidence of their long-term therapeutic effects. Lifestyle changes, including increased coital activity, smoking cessation, and consumption of cranberry juice or extract (for recurrent urinary infections) can relieve GSM symptoms. Recently, selective estrogen receptor modulators (SERMS), or estrogen agonists/antagonists have entered the prescription market for GSM treatment. Tamoxifen, Raloxifene, Bazedoxifene (alone), and Arzoxifene demonstrate no specific beneficial vaginal effects on GSM although they frequently cause leukorrhea. In contrast, both Lasofoxifene (un-marketed) and Ospemifene improve the signs and symptoms of GSM. Ospemifene is a metabolite of Toremifene. Ospemifene has been demonstrated to increase superficial cells, decrease parabasal cells and vaginal pH, and relieves both dryness and dyspareunia. Together such physiological changes improved menopausal sexual function in trials using validated instruments. Despite all of these options, many women remain untreated and symptomatic.