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Treatment of Vulvovaginal Atrophy

Educational Objective
To understand how to diagnose and treat Vulvovaginal Atrophy in women
1 Credit CME

Symptoms of vulvar and vaginal atrophy, such as dyspareunia, dryness, burning, and pruritus, affect more than 50% of midlife and older women.1 Previously, the term vulvovaginal atrophy (VVA) was used to refer to these symptoms. However, there is increasing recognition that the loss of estrogen resulting from the cessation of ovarian function may also promote urinary frequency and urgency, prompting a new broader term, genitourinary syndrome of menopause (GSM).1 GSM includes symptomatic VVA as well as lower urinary tract symptoms related to low estrogen levels. GSM symptoms adversely affect quality of life and cause pain during sex, loss of libido, avoidance of intimacy, urinary urgency, dysuria, and recurrent symptomatic urinary tract infections. If left unmanaged, GSM can be progressive and often debilitating, with severe symptoms and anatomic changes sometimes requiring pelvic floor physical therapy and vaginal dilator therapy. Many women who have GSM symptoms are undiagnosed and untreated, and women often do not identify GSM as the cause of their symptoms.

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Article Information

Corresponding Author: Carolyn J. Crandall, MD, MS, David Geffen School of Medicine, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, 1100 Glendon Ave, Ste 850, Room 858, Los Angeles, CA 90024 (ccrandall@mednet.ucla.edu).

Published Online: September 26, 2019. doi:10.1001/jama.2019.15100

Conflict of Interest Disclosures: None reported.

References
1.
Portman  DJ, Gass  ML; Vulvovaginal Atrophy Terminology Consensus Conference Panel.  Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society.  Menopause. 2014;21(10):1063-1068.PubMedGoogle ScholarCrossref
2.
Rioux  JE, Devlin  C, Gelfand  MM,  et al.  17β-estradiol vaginal tablet versus conjugated equine estrogen vaginal cream to relieve menopausal atrophic vaginitis.  Menopause. 2000;7(3):156-161.PubMedGoogle ScholarCrossref
3.
 Imvexxy—another estradiol vaginal insert for dyspareunia.  Med Lett Drugs Ther. 2018;60(1555):147-148.PubMedGoogle Scholar
4.
 Prasterone (Intrarosa) for dyspareunia.  Med Lett Drugs Ther. 2017;59(1529):149-150.PubMedGoogle Scholar
5.
Simon  J, Nachtigall  L, Ulrich  LG,  et al.  Endometrial safety of ultra-low-dose estradiol vaginal tablets.  Obstet Gynecol. 2010;116(4):876-883.PubMedGoogle ScholarCrossref
6.
Crandall  CJ, Hovey  KM, Andrews  CA,  et al.  Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women’s Health Initiative observational study.  Menopause. 2018;25(1):11-20.PubMedGoogle ScholarCrossref
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