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Dx Atrophic Vaginitis Treatments: Dx Vulvodynia. Read more..

The EMAS Clinical guide: low dose vaginal estrogens are acceptable for postmenopausal vaginal atrophy. Use after breast cancer is accepted as standard of care.
Compounded estradiol cream here or estradiol creams from Canada costs one-third that of Premarin® or Estrace® .01% vaginal cream. The generic estradiol 1mg tablets are equally effective and can be inserted vaginally and are least extensive at $12.00 for 100 tablets.

Atropic Vaginitis

" Background.
Atrophic vaginitis (AV), the result of estrogen deficiency, is experienced by almost half of postmenopausal women. AV contributes to a host of symptoms including itching, burning, dryness, and irritation, all of which can lead to dyspareunia. A decline in estrogen alters the vaginal flora, which permits bacterial overgrowth, sometimes accompanied by vaginal discharge. Declining estrogen also affects the urinary tract, leading to thinning of the bladder and urethral linings and potentially resulting in chronic dysuria and an increased incidence of urinary tract infections. The sensitivity of a discussion about painful intercourse may inhibit many women from mentioning this concern or seeking treatment.

The diagnosis of AV is primarily clinical and begins with the ascertainment of specific symptoms: vaginal dryness, burning, pruritis, abnormal discharge, and dyspareunia. These symptoms may be more prominent in women who are younger at the time of menopause, who are non-white, who have diabetes, and who have a lower body mass index. Additionally, symptoms have been found to be more severe in women who have not experienced a vaginal delivery. On examination, providers will note atrophy of the labia major and minora with loss of subcutaneous fat. Along with dry labia, vulvar lesions and sparse pubic hair are common. The vaginal epithelium may appear pale, smooth, dry, and friable, with a loss of rugae. Areas of inflammation with patchy erythema and petechiae may be noted. A test of vaginal pH, using simple litmus paper held against the vaginal wall until moist, can help to clarify the diagnosis. A pH level > 5.0 is indicative of AV.

Treatment begins with vaginal moisturizers and lubricants, a variety of which are available over the counter. When these are not effective, vaginal or systemic estrogen therapy, either alone or combined with progesterone, should be initiated at the lowest effective dose for the shortest duration needed. Both routes are effective, although the safety of systemic hormone therapy continues to be a concern, particularly in some subgroups of women. Estrogen-only vaginal products are available as creams, which tend to cost less, or vaginal tablets, which are less messy. Either should be used daily for 2 weeks to induce a therapeutic response and then continued as maintenance 2-3 times per week. Vaginal estrogen rings offer convenience because they need only be inserted every 90 days." [From:Pearson T; The Journal for Nurse Practitioners. 2011;7:502-505]

Medications Used in Treatment
1. Estradiol tablets: Estrace®/ estradiol 1mg
2. Premarin vaginal cream
3. Estradiol vaginal cream: Estrace® vaginal cream
4. Vagifem®: estradiol
5. Osphena®: ospemifene
6. Androgens: Testosterone cream 2% compounded

Forty years ago, it was common knowledge that a 2% compounded testosterone cream would cure dry vaginal tissue: lichen sclerosis, atrophic vaginitis, pain with intercourse, improve sex drive and may assist in cases of vulvodynia. Use of Osphena and topical lidocaine do not treat the cause.

*From the Management of symptomatic vulvovaginal atrophy: 2013 Position Statement of the North American Menopause Society. The small amount of estrogen is mostly locally absorbed. Even oncologists treating women with breast cancer are not overly concerned about the estrogen vaginal products.

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