BHRT

Treat Local: Vaginal HRT for Postmenopausal Sexual Health

June 22, 2022

By: Rachel Noonan, PharmD

Cultivating an open and honest culture with your patients can be challenging, particularly when it comes to sexual health and wellbeing.  Studies highlight the consequences of avoiding the topic (intimacy restraint, relationship dissatisfaction, personal distress), and an escalating number of women are struggling to talk about it. Unaware of their options, help is needed to begin important conversations about the genitourinary symptoms affecting over 60% of postmenopausal women.

It is no secret the phases of menopause can wreak havoc on health systems. Estrogen’s drastic drop triggers a cascade of undesirable shifts. Vaginal decreases in blood flow, increases in pH, and changes to microbiota all contribute to GSM (Genitourinary syndrome of menopause).  As stated in Scavello et al Sexual Health in Menopause Review, ‘Women affected by GSM often report dryness, decreased lubrication, discomfort or pain with sexual activity, post-coital bleeding, irritation/burning/itching of the vulva and/or vagina and pelvic pain.’

While vasomotor issues will likely lessen over time, GSM-related sexual discomfort will not.  Even with systemic hormone replacement on board, many women continue to experience vaginal problems. If mild vaginal dryness is the chief complaint, non-hormonal lubricants or moisturizers may provide temporary relief. But too often, women experience a combination of debilitating symptoms requiring additional care, such as localized hormone replacement therapy.

Dehydroepiandrosterone (DHEA) metabolizes into sex hormones, activating these receptors along the vaginal wall with local administration. Daily DHEA 0.5% therapy in a clinical trial conducted by Labrie et al resulted in statistically significant improvement in vaginal dryness and dyspareunia, including a positive impact on vaginal mucosa and pH.

Applied vaginally, low-dose estradiol, estriol, or their combination continues to be vital in alleviating moderate to severe postmenopausal complaints. Regardless of dosage form, local therapy improves GSM symptoms, positively influencing sexual dysfunction. With an abundance of well-researched options, patients have the freedom of selecting localized HRT based on symptom severity and personal preference.

Compounded creams offer the ease of adjustable dosing, customizable to combine ingredients unavailable commercially.  Although evidence suggests limited systemic absorption with vaginal application, further investigation is warranted to fully appreciate the long-term safety profile of DHEA and estrogen in patients with a history of hormone-dependent cancer.

Time and time again, female heath complaints are marginalized. Utilizing meaningful, localized hormone intervention may eliminate the secrecy surrounding postmenopausal sexual dysfunction. Prioritizing sexual health with female patients will encourage the undertreated women in your clinical space to advocate for their needs.

References

  1. The NAMS 2017 Hormone Therapy Position Statement Advisory Panel. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause. 2017 Jul;24(7):728-753. doi: 10.1097/GME.0000000000000921. PMID: 28650869.
  2. Scavello, I., Maseroli, E., Di Stasi, V., & Vignozzi, L. (2019). Sexual Health in Menopause. Medicina (Kaunas, Lithuania), 55(9), 559. https://doi.org/10.3390/medicina55090559
  3. Heidari M, Ghodusi M, Rezaei P, Kabirian Abyaneh S, Sureshjani EH, Sheikhi RA. Sexual Function and Factors Affecting Menopause: A Systematic Review. J Menopausal Med. 2019 Apr;25(1):15-27. doi: 10.6118/jmm.2019.25.1.15. Epub 2019 Apr 25. PMID: 31080785; PMCID: PMC6487288.
  4. Shim S, Park KM, Chung YJ, Kim MR. Updates on Therapeutic Alternatives for Genitourinary Syndrome of Menopause: Hormonal and Non-Hormonal Managements. J Menopausal Med. 2021 Apr;27(1):1-7. doi: 10.6118/jmm.20034. PMID: 33942583; PMCID: PMC8102810.
  5. Naumova I, Castelo-Branco C. Current treatment options for postmenopausal vaginal atrophy. Int J Womens Health. 2018 Jul 31;10:387-395. doi: 10.2147/IJWH.S158913. PMID: 30104904; PMCID: PMC6074805.
  6. Labrie, Fernand MD, PhD; Archer, David F. MD; Koltun, William MD; Vachon, Andrée MD; Young, Douglas MD; Frenette, Louise MD; Portman, David MD; Montesino, Marlene MD; Côté, Isabelle BSc; Parent, Julie PhD; Lavoie, Lyne MSc; Beauregard, Adam BSc, MBA; Martel, Céline PhD; Vaillancourt, Mario BSc, MBA; Balser, John PhD; Moyneur, Érick BSc, MA members of the VVA Prasterone Research Group Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause, Menopause: March 2016 – Volume 23 – Issue 3 – p 243-256 doi: 10.1097/GME.0000000000000571
  7. Simon JA, Nappi RE, Kingsberg SA, Maamari R, Brown V. Clarifying Vaginal Atrophy’s Impact on Sex and Relationships (CLOSER) survey: emotional and physical impact of vaginal discomfort on North American postmenopausal women and their partners. Menopause. 2014 Feb;21(2):137-42. doi: 10.1097/GME.0b013e318295236f. PMID: 23736862.