The Utility of Vaginal Estrogens for Managing GSM

Commercially available vaginal estrogens provide postmenopausal women with effective options for the management of genitourinary syndrome of menopause (GSM), according to a review published by the Society of Gynecologic Surgeons in Obstetrics & Gynecology.

“Among those patients with more bothersome vulvovaginal atrophy symptoms or urinary complaints of urgency, frequency, nocturia, or stress urinary incontinence and urgency urinary incontinence, vaginal estrogen therapy may offer substantial improvement in symptoms,” wrote David D. Rahn, MD, of the University of Texas Southwestern Medical Center, and colleagues from the Society of Gynecologic Surgeons Systematic Group Review.

For the review, the authors identified 44 studies that compared vaginal estrogen application with other methods used to treat genitourinary syndrome of menopause. Treatment methods included in the studies were vaginal estrogen tablets, creams, suppositories, and rings, and comparators included placebo, no intervention, systemic estrogen therapy, vaginal lubricants, and estriol products not approved in the United States but commonly used in other countries.

Fourteen of the studies compared vaginal estrogens with placebo. Results of these studies showed that the use of vaginal estrogen improved a variety of common genital and urinary complaints, including vaginal dryness, itching, dyspareunia, dysuria, urinary urgency and frequency, stress urinary incontinence, and urgency urinary incontinence.

The authors said that no significant differences in adverse events were found in the studies for patients treated with vaginal estrogen compared with placebo. However, they acknowledged that the data included in the studies on adverse events was variable.

Eighteen studies comparing vaginal estrogens to each other were identified, and the results showed that there were no major differences in efficacy or safety between various vaginal estrogen preparations. In addition, very low rates of endometrial hyperplasia and adenocarcinoma were diagnosed among women receiving vaginal estrogen.

Finally, when comparing vaginal estrogens to nonhormonal lubricants, those patients who had at least two symptoms of vulvovaginal atrophy derived greater benefit from the use of vaginal estrogens than they did with nonhormonal lubricants.

Based on the results of this review, the group included several guidelines, three of which were graded as strong guidelines with high-quality supporting evidence:

- The group recommended application of vaginal estrogen, such as estradiol vaginal ring and tablet, when patients present with urogenital atrophy complaints or are reporting urgent urinary incontinence.

- They recommended application of any commercially available vaginal estrogen at approved doses and frequencies in patients with urogenital atrophy complaints.

- They recommended application of vaginal estrogen, such as estradiol vaginal ring and estradiol products, in patients who present with recurrent urinary tract infection with or without urogenital atrophy complaints.

However, the authors also acknowledged that “nonhormonal lubricants may be a useful alternative for patients with mild or few urogenital atrophy complaints and in women at risk for estrogen-responsive neoplasia.”