How effective are postmenopausal vulvovaginal symptom medications?

By Jane Lewis
Prescribed vaginal estradiol tablets and specific over-the-counter vaginal moisturiser may be no better than simple moisturiser in reducing postmenopausal vulvovaginal symptoms, according to US research published in JAMA Internal Medicine.

The multicentre trial included 302 women (mean age, 61 years) with moderate-to-severe vulvovaginal symptoms, randomised to receive vaginal 10 mcg estradiol tablet (daily for two weeks, then twice weekly) plus placebo gel (three times a week); placebo tablet plus vaginal moisturiser; or dual placebo. Most participants (60%) reported pain with penetration as their most bothersome symptom, followed by vulvovaginal dryness (21%). Over 12 weeks’ treatment, women in all groups showed comparable reductions in most bothersome symptom severity: estradiol, -1.4; moisturiser, -1.2; and placebo, -1.3. No significant differences were seen between estradiol or moisturiser compared with placebo.

The researchers said shared decision-making for treating postmenopausal vulvovaginal symptoms could be based on cost and patient preference. ‘Vaginal estradiol tablets appear not to add benefit beyond vaginal gel or moisturiser,’ they concluded.

The authors of an invited commentary suggested that, based on these results, women who had vulvovaginal symptoms should choose the cheapest moisturiser or lubricant available until new evidence suggested otherwise.

Gayle Fischer OAM, Associate Professor in Dermatology at Sydney Medical School Northern, The University of Sydney, said this was a well-conducted study, so the results should be taken seriously.

She said the study raised the important issue of cost of oestrogen versus using a moisturiser. ‘However, my experience with postmenopausal women is that it is not just dryness and dyspareunia that bothers them. A big issue is also incontinence,’ she told Medicine Today.

She noted that incontinence was not mentioned in the study but was an important issue that could be mitigated with topical oestrogen.

An important shortcoming of the trial was that it stopped at 12 weeks, as it could take about three months for oestrogen to make a difference, Associate Professor Fischer said.

‘If patients only have problems with dryness, they should try moisturiser and lubricants first,’ she said. ‘If this is not effective, then based on just this one study, I don’t think clinicians should be too hasty to deny them a trial of oestrogen. Women are already unnecessarily scared of oestrogen, and I would not like to see this study used to support unjustified fears,’ she added.
JAMA Intern Med 2018; doi:10.1001/jamainternmed.2018.0116.
JAMA Intern Med 2018; doi:10.1001/jamainternmed.2018.E1-E2.