Treatments in the pipeline
For decades, hormone-based treatments have been the predominant therapeutic option for vaginal dryness. Often they are a secondary benefit of hormone therapy for vasomotor symptoms and osteoporosis. Estrogen can be delivered in the form of oral tablet, transdermal patch, gel, spray, or vaginal ring for systemic use, or as vaginal cream, ring, or tablet for local use.
However, despite data to the contrary and our reassurances to the patient about overall safety, a large number of women, and many primary care providers, are no longer inclined to use short- or long-term HRT in any presentation.
Other women may have risk factors that contraindicate exogenous hormones.
Nonhormonal options for vaginal dryness and dyspareunia are limited, and there are no approved systemic or oral nonestrogen options. Over-the-counter topical lubricants can ease some of the symptoms of VVA temporarily and allow successful vaginal penetration in many cases. Some may cause vaginal warming and pleasant sensations, but overall they treat the symptom rather than the source of pain. Moreover, many patients consider local lubricants messy and inconvenient and claim they “ruin the mood.”
The use of vaginal dilators along with estrogen or lubricant therapy is an often-forgotten adjunct to therapy for dyspareunia caused by VVA (FIGURE 4).
FIGURE 4 Mechanical dilation of the vagina is a useful adjunct
Mechanical dilation is often needed to restore penetration capability in the vagina, even after hormonal treatment. The focus should be on the vaginal introitus, with the top 25% to 35% of the dilator inserted into the opening once a day for 15 minutes, increasing the dilator diameter over time.
New SERMs are in development
Preclinical and clinical research into the diverse class of selective estrogen receptor modulators (SERMs) to treat estrogen-mediated disease produced tamoxifen for breast cancer prevention and raloxifene for both vertebral osteoporosis and breast cancer prevention. Each SERM seems to have unique tissue selectivity. The antiestrogenic activity of tamoxifen and raloxifene extends to the vagina and can exacerbate vaginal dryness.
A new generation of orally active SERMs is under investigation specifically for the treatment of chronic vaginal symptoms. These new agents target the nonvaginal treatment of VVA and associated symptoms. The first oral SERM for long-term treatment of these symptoms, ospemifene (Ophena), may become available in the near future. It is a novel SERM that has both anti-estrogenic and estrogenic actions, depending on the tissue. It was shown to significantly improve both vaginal dryness and dyspareunia in a large placebo-controlled trial.15