Vaginal Estrogen for Genitourinary Syndrome of Menopause

Abstract

OBJECTIVE To comprehensively review and critically assess the literature on vaginal estrogen and its alternatives for women with genitourinary syndrome of menopause and to provide clinical practice guidelines. DATA SOURCES MEDLINE and Cochrane databases were searched from inception to April 2013. We included randomized controlled trials and prospective comparative studies. Interventions and comparators included all commercially available vaginal estrogen products. Placebo, no treatment, systemic estrogen (all routes), and nonhormonal moisturizers and lubricants were included as comparators. METHODS OF STUDY SELECTION We double-screened 1,805 abstracts, identifying 44 eligible studies. Discrepancies were adjudicated by a third reviewer. Studies were individually and collectively assessed for methodologic quality and strength of evidence. TABULATION, INTEGRATION, AND RESULTS Studies were extracted for participant, intervention, comparator, and outcomes data, including patient-reported atrophy symptoms (eg, vaginal dryness, dyspareunia, dysuria, urgency, frequency, recurrent urinary tract infection (UTI), and urinary incontinence), objective signs of atrophy, urodynamic measures, endometrial effects, serum estradiol changes, and adverse events. Compared with placebo, vaginal estrogens improved dryness, dyspareunia, urinary urgency, frequency, and stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). Urinary tract infection rates decreased. The various estrogen preparations had similar efficacy and safety; serum estradiol levels remained within postmenopausal norms for all except high-dose conjugated equine estrogen cream. Endometrial hyperplasia and adenocarcinoma were extremely rare among those receiving vaginal estrogen. Comparing vaginal estrogen with nonhormonal moisturizers, patients with two or more symptoms of vulvovaginal atrophy were substantially more improved using vaginal estrogens, but those with one or minor complaints had similar symptom resolution with either estrogen or nonhormonal moisturizer. CONCLUSION All commercially available vaginal estrogens effectively relieve common vulvovaginal atrophy-related complaints and have additional utility in patients with urinary urgency, frequency or nocturia, SUI and UUI, and recurrent UTIs. Nonhormonal moisturizers are a beneficial alternative for those with few or minor atrophy-related symptoms and in patients at risk for estrogen-related neoplasia. CLINICAL TRIAL REGISTRATION PROSPERO International prospective register of systematic reviews, http://www.crd.york.ac.uk/PROSPERO/,CRD42013006656.

Low-dose 17-β-estradiol cream for vaginal atrophy in a cohort without prolapse: Serum levels and vaginal response including tissue biomarkers associated with tissue remodeling

“…Importantly, these improvements occurred without significantly elevating their serum estradiol levels when sampled with a highly-sensitive radioimmunoassay. This information is consistent with the published literature and can be used when counseling older women with vaginal atrophy who may be concerned about initiating intravaginal estrogen therapy [1, 15–18]. …”

“…Low dose vaginal estrogen is an effective treatment for atrophy symptoms [17–18]. This study showed that older women using 50mcg of intravaginal estradiol nightly for 8 weeks followed by twice weekly for 8 weeks had improvements in their VMI and vaginal symptoms of dryness and itching.…”

“…Consequently, even though current guidelines support the use of vaginal estrogen to treat vaginal atrophy, many women have been reluctant to use any form of estrogen [15–18]. Treatment of vaginal atrophy to optimize vaginal heath has also become common in the surgical and nonsurgical management of pelvic floor complaints including prolapse and urinary incontinence.…”

Management of Menopausal Symptoms

“…Systematic reviews have noted that tablets, the ring, and creams have comparable efficacy in treating vulvovaginal symptoms. 74 Vaginal estrogen has also been found to reduce risk of recurrent UTIs and overactive bladder symptoms in menopausal women. The low-dose vaginal estradiol ring is approved to treat urinary urgency and dysuria.…”

High molecular weight hyaluronic acid: a two‐pronged protectant against infection of the urogenital tract?

“…Postmenopausal women are characterised by reduced oestrogen levels and those suffering rUTIs typically show a vaginal pH above 4.5,12 suggesting that the reduced oestrogen levels impact negatively on Lactobacilli growth, which adversely affects the vaginal microbiome 13, 14, 15. In support of a role for oestrogen in the innate defence of the urogenital tract, topical, but not oral oestrogen treatments have proven successful in reducing infections with these effects mediated through the vaginal commensal populations and the urogenital innate defences 16, 17, 18, 19. However, because of the side effects, the use of topical vaginal oestrogen is not always appropriate for all women20 and hence its therapeutic potential in treating rUTIs is limited.…”