Management Of Vaginal Atrophy Research Articles

Management of vaginal atrophy: a real mess. Results from the AGATA study

Objectives: To investigate the management of vaginal atrophy (VA) in a population-based study.Study design: A sub-study of a cross-sectional multicenter study on 913 postmenopausal women.Main outcome measures: Management of VA was investigated on the 274 women referring having received a previous diagnosis of VA.Results: Women had received, no therapy (9.8%), systemic hormones (9.2%), intra-vaginal estrogens (44.5%) or local non-hormonal (36.5%) therapy. There was heterogeneity of treatments. Local therapies were given in cycles, and used for a length of time ranging from 1 to 12 months. At the time of the investigation 59.5% of these women were not on treatment, either because following the physician’s indication (31.1%) or because spontaneously withdrawing from treatment (68.9%). Reasons for withdrawing from therapy were insufficient symptom relief (46.6%), messiness (24.3%), difficulty in application (7.8%) and vaginal discharge (1.9%). At the time of investigation only 2.9% of treated women did not suffer from VA.Conclusions: This study underlines the presence of a great confusion about the therapy used for VA, along with patients’ dissatisfaction with actual treatments. The emerging evidence is that in real world VA remains untreated.

Medical and patient attitude towards vaginal atrophy: the AGATA study

Objectives: To provide data on current management of vaginal atrophy (VA) in a nationwide setting.Methods: A cross-sectional, multicenter study was made in 913 postmenopausal women consulting 22 gynecological outpatient services. VA was diagnosed with a combination of subjective symptoms and objective evaluations. Women with a previous diagnosis and those with a new diagnosis of VA filled additional questionnaires regarding modalities of VA management and reasons for missing diagnosis, respectively.Results: 730/913 (80%) women had ever had a diagnosis of VA. In 274 (37.5%), the diagnosis was made prior to, and in 456 (62.5%) during the investigation. Of women with a new VA diagnosis, 81.1% had never discussed their symptoms with the health-care practitioner (HCP), and 78.7% (n = 359) had never been questioned by an HCP. Of women with a previous VA diagnosis, 90.2% had been treated with systemic (10.1%), local hormonal (49.4%) or local non-hormonal (30.5%) therapy. At the time of investigation, 61.9% of these women had stopped treatment, with only 3.3% having been successfully cured.Conclusions: VA is highly prevalent in postmenopausal women. Its current management and treatment seem to be highly unsatisfactory and can be improved by medical sensitization and patient education.

Ovarian Ablation in Breast Cancer Patients and the Possibility of Influencing Treatment Side Effects

Ovarian suppression or ovarian ablation used in treatment of breast carcinoma results in temporary or permanent menopause and associated menopausal symptoms - most frequently vasomotoric symptoms (hot flashes, sweats), vaginal atrophy, sleep disturbances. Patients can also experience frequent decrease in bone density (osteopenia, osteoporosis), mood swings or depression, less frequently cardiac toxicity. Managements of these symptoms is complex. As hormonal replacement therapy (estrogens or combined estrogen/gestagen therapy) is contraindicated in women with breast carcinoma, other available options include non-hormonal pharmacological or non-pharmacological methods or their combinations. Women should be advised about cooling techniques and how to avoid known triggers; these measures should be combined with other non-pharmacological and pharmacological intervention. Non-pharmacological methods include the use of acupuncture or cognitive behavioral therapy. Some tips to help stay cool and decrease hot flashes - avoid hot beverages, spicy food, limit coffee or alcohol intake, dress in layers of clothing that can be removed if necessary. Pharmacological options include most frequently antidepressants - SSRI (selective serotonin reuptake inhibitor), SNRI (serotonin norepinephrin reuptake inhibitor), or alternatively gabapentin or pregabali. A very promising drug is paroxetine with a lot of clinical trials. Only this drug has FDA approval for the indication of hot flashes. Paroxetine can lead to disproportional changes in plasma levels of drug in CYP2D6 metabolism and thus it is not suitable for combination of paroxetine with tamoxifen. Several studies demonstrated the effectiveness of the newer generation of SSRI - citalopram, escitalopram, sertralin and duloxetin in ameliorating hot flashes. Venlafaxine in dose 75 or 150 mg has been associated with a 61% reduction in hot flashes frequency if compared to 27% reduction with placebo. Medroxyprogesterone acetate and megestrol acetate were investigated especially in patients with breast cancer history and both drugs demonstrate an effect in hot flashes treatment. Management of vaginal atrophy is challenging. Vaginal dryness/atrophy can be relieved with use of topical lubricants/gels or possibly in highly symptomatic patients with short term use of topical estrogens. As these symptoms require highly complex management, multidisciplinary approach is recommended.Key words: breast cancer - postmenopause - ovarian suppression - postmenopausal osteoporosis - therapyThis work was supported by grant of the Czech Ministry of Health - RVO (MOÚ, 00209805).The author declares she has no potential conflicts of interest concerning drugs, products, or services used in the study.The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 20. 7. 2016Accepted: 10. 8. 2016.

Management of Vaginal Atrophy: Implications from the REVIVE Survey

Vulvar and vaginal atrophy (VVA) is a chronic and progressive medical condition common in postmenopausal women. Symptoms of VVA such as dyspareunia, vaginal dryness, irritation, and itching can negatively impact sexual function and quality of life. The REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey assessed knowledge about VVA and recorded attitudes about interactions with healthcare providers (HCPs) and available treatment options for VVA. The REVIVE survey identified unmet needs of women with VVA symptoms such as poor understanding of the condition, poor communication with HCPs despite the presence of vaginal symptoms, and concerns about the safety, convenience, and efficacy of available VVA treatments. HCPs can address these unmet needs by proactively identifying patients with VVA and educating them about the condition as well as discussing treatment preferences and available therapies for VVA.

Overcoming resistance and barriers to the use of local estrogen therapy for the treatment of vaginal atrophy

The purpose of this review is to summarize current information regarding the pathophysiology and management of vaginal atrophy (sometimes called “atrophic vaginitis”) and to identify barriers to its treatment with local (or “topical”) vaginal estrogen therapy. Relevant clinical trials, meta-analyses, and reviews were identified through the PubMed database. Local estrogen therapy is effective and safe for treatment of vaginal atrophy; however, barriers to treatment (eg, patient reluctance to discuss the condition, misinformation, incomplete understanding of the effectiveness and safety of available therapies) result in its underuse. Health care providers can help overcome barriers to effective treatment of vaginal atrophy by facilitating discussion with women about vaginal health. Discussions should occur at routine preventive health care examinations and during episodic visits when patients present with symptoms of vaginal atrophy. Education and counseling should include information on the importance of maintaining vaginal health and the benefits and risks of treatment, including the demonstrated effectiveness and safety profile of low-dose local estrogen therapy.

Practical Aspects in the Management of Vaginal Atrophy and Sexual Dysfunction in Perimenopausal and Postmenopausal Women

The decline in circulating estrogen levels in peri- and postmenopause has a wide range of physiological effects, including atrophy of tissues in the urogenital tract. Vaginal atrophy is an important contributor to postmenopausal sexual dysfunction. To provide a framework for clinical evaluation and clinical management of sexual dysfunction secondary to vaginal atrophy. Conduct a brief overview of literature on evaluation and treatment of vaginal atrophy, augmented with the authors' clinical observations and experience. Estrogen decline disrupts many physiological responses characteristic of sexual arousal, including smooth muscle relaxation, vasocongestion, and vaginal lubrication; genital tissues depend on continued estrogen and androgen stimulation for normal function. An upward shift in vaginal pH as the result of vaginal atrophy alters the normal vaginal flora. Reduced lubrication capability and reduced tissue elasticity, in addition to shortening and narrowing of the vaginal vault, can lead to painful and/or unpleasant intercourse. At the same time, diminished sensory response may reduce orgasmic intensity. Other contributors to peri- and postmenopausal sexual dysfunction include reduced androgen levels, aging of multiple body systems, and side-effects of medications. Workup of sexual health problems starts by taking a comprehensive sexual, medical, and psychosocial history, followed by complete physical examination and laboratory evaluation. Clinical management includes measures to preserve and enhance overall health, adjustment of medication regimes to reduce or avoid side-effects, and topical or systemic hormone supplementation with estrogens and/or androgens. No single therapeutic approach is appropriate for every woman with peri- or postmenopausal sexual dysfunction; instead, treatment should be based on a comprehensive evaluation and consideration of medical and psychosocial contributors to the individual's dysfunction. Further research is required to establish optimal regimens of hormonal and nonhormonal agents, including dosages/dosage forms and duration of treatment, for specific subtypes of sexual dysfunction.

The Detection and Management of Vaginal Atrophy

The Detection and Management of Vaginal Atrophy

A cohort study of topical vaginal estrogen therapy in women previously treated for breast cancer

Objective: To estimate the risk of recurrence of breast cancer associated with the use of topical vaginal estrogen therapy in the management of vaginal atrophy in women previously treated for breastcancer.Methods: The study group comprised 1472 women with histologically confirmed breast cancer. In 69 of these subjects (4.7%) their only bothersome menopausal problems were vaginal symptoms.In these women, poorly absorbed topical vaginal estrogen cream or tablets were used. The response of these patients was compared with that of the rest of the database. A Cox regression analysis was performedusing sex hormone usage after diagnosis as a time-dependent covariate. Disease-free interval was the outcome measured. Results are expressed as a hazard ratio with 95% confidence intervals. The hazard rateis defined as the probability of disease recurrence or of a subject dying from breast cancer over the study period. A second analysis was performed adjusting for factors known to affect breast cancer prognosis.Results: Hormone usage was entered as a time-dependent covariate with disease-free interval as the outcome. Subjects who used a topical estrogen alone for menopausal symptoms had an uncorrected hazardratio of 0.30 (95% confidence interval (CI) 0.11-0.80, p = 0.02). The corrected hazard ratio was 0.57 (95% CI 0.20-1.58, p = 0.28). The hazard rate for a subject dying was not analyzed, asthere were too few numbers.Conclusions: Although the small numbers of this study preclude a definitive result, topical estrogen usage does not appear to be associated with an increased risk ofrecurrence of breast cancer.