Intravaginal estrogen shows promise for treating postmenopausal vaginal atrophy

Intravaginal estrogen shows promise for treating postmenopausal vaginal atrophy | Image Credit: © DragonImages - © DragonImages - stock.adobe.com.

Intravaginal estrogen therapy has promise for improving vaginal atrophy and vaginitis in postmenopausal women, according to a recent study published in the Journal of Menopausal Medicine.¹

The genitourinary syndrome of menopause (GSM) is defined as the presentation of menopausal symptoms such as genital symptoms, sexual symptoms, and urinary symptoms. These symptoms are often treated using estrogen-based hormone replacement therapy (HRT), including nasal sprays, oral tablets, and local vaginal routes.

As local vaginal therapies lead to less side effects than systemic routes, topical estrogen is recommended as treatment for women with GSM.² However, more data is needed to assess various health outcomes in women receiving HRT.¹

Investigators conducted a study to evaluate the safety and efficacy of local estrogen toward improving postmenopausal vaginal symptoms. Articles published up to July 2023 were identified using the Google Scholar, PubMed, ClinicalTrials.Gov, Cochrane Library, and ScienceDirect databases.

Eligibility criteria included double-arm studies, randomized controlled trials (RCTs), evaluating intravaginal estrogen supplementation and vaginal atrophy or vaginitis in post-menopausal women, having at least 2 weeks of follow-up, patients receiving bilateral oophorectomy, and including all modes of local vaginal therapy.

Relevant primary outcomes included vaginal PH, dyspareunia and vaginal dryness, and maturation value, while secondary outcomes were common adverse events. Articles were screened by 2 independent researchers.

Extracted data included year, author study design, sample size, location, age, intervention, follow-up time, comparator, common adverse events, maturation value, and pH. Disagreements were resolved by discussion or through a third reviewer.

There were 18 RCTs included in the final analysis, encompassing 4723 patients receiving estrogen and 1580 receiving placebo. Patients were aged a mean 49 years, and follow-up periods ranged from 2 weeks to 24 weeks.

Individuals taking estrogen had a non-significant mean maturation value overall, but an increase in superficial cells and decrease in parabasal cells were observed in subgroup analyses, with mean differences (MDs) of 19.28 and -24.85, respectively. Heterogeneity was not significantly decreased in a leave one out sensitivity analysis.

The MD in vaginal pH for patients using estrogen was decreased by -0.94, indicating a significant reduction. For the overall follow-up, the decrease in MD was -1.01. However, differences were insignificant during the 3- to 6-week and 12-week follow-up.

In subgroup analyses based on estrogen doses, a significant reduction in vaginal pH was found for 15 µg, with an MD of -0.92. However, 50 µg and under 2.5 µg doses both had MDs of 0.10, showing insignificant changes.

A significant reduction of dyspareunia was also reported among patients taking estrogen, with and MD of -0.52. While this reduction was significant overall, subgroup differences between weeks 3 to 4 and week 12 were insignificant. During the week 12 follow-up, the MD was significant at -0.31.

No significant impact on vaginal dryness was reported following estrogen intake. The association between estrogen use and adverse events was also initially insignificant, but removal of a single sensitivity analysis revealed significant results, with a relative risk (RR) of 0.91.

There were also significant subgroup differences between estrogen use and common adverse events. The RR for vulvovaginal mycotic infection was 2.82, making it the most common adverse event. This was followed by vulvovaginal pruritis with an RR of 0.52.

These results indicated significant improvements in vaginal atrophy and vaginitis symptoms in postmenopausal women following estrogen therapy use. Investigators concluded this data empowers health care providers to offer individualized treatment plans for quality-of-life improvement in these patients.

References

1. Ali A, Iftikhar A, Tabassum M, Imran R, Usama Shaid M, Rehan Hashmi M. Efficacy and safety of intravaginal estrogen in the treatment of atrophic vaginitis: A systematic review and meta-analysis. J Menopausal Med. 2024;30(2):88-103. doi:10.6118/jmm.23037
2. Cardozo L, Bachmann G, McClish D, Fonda D, Birgerson L. Meta-analysis of estrogen therapy in the management of urogenital atrophy in postmenopausal women: second report of the Hormones and Urogenital Therapy Committee. Obstet Gynecol. 1998;92:722–727. doi:10.1016/s0029-7844(98)00175-6