Guideline sources The following summarized guidelines for the evaluation and management of vulvovaginal atrophy are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2021; 2014), the Endocrine Society (ES 2015), the American College of Obstetricians and Gynecologists (ACOG 2014), the North American Menopause Society (NAMS 2013), and the American Association of Clinical Endocrinologists (AACE 2011). 1 2 3 4 5 6 7 Guidelines 1. Screening and diagnosis Indications for screening: As per SOGC 2021 guidelines, obtain comprehensive screening for genitourinary syndrome of menopause symptoms on an ongoing basis in menopausal females, as symptoms can present insidiously and become bothersome long after the menopausal transition. A As per SOGC 2014 guidelines, address vulvovaginal atrophy in all middle-aged females complaining of sexual dysfunction. A https://web.pathway.md/diseases/recLXBFI2uX50wJzY 1/6 6/29/23, 3:45 AM Vulvovaginal atrophy Pathway 2. Diagnostic investigations Evaluation of vaginal bleeding: As per ES 2015 guidelines, obtain evaluation to rule out pelvic pathology, most importantly, endometrial hyperplasia and cancer in patients with persistent unscheduled bleeding while taking menopausal hormone therapy. B As per SOGC 2014 guidelines, evaluate all patients with postmenopausal bleeding, defines as any unexpected vaginal bleeding occurring after 12 months of amenorrhea. A As per NAMS 2013 guidelines, obtain a thorough evaluation including transvaginal ultrasound and/or endometrial biopsy in postmenopausal patients with an intact uterus presenting with spotting or bleeding. A Evaluation of sexual dysfunction: As per SOGC 2021 guidelines: Elicit a sexual screening history and perform a physical examination in the initial evaluation of menopausal females. B Categorize the patient's problem as related to desire, arousal, pain, or orgasm, in order to facilitate treatment and to triage care. B As per SOGC 2014 guidelines, elicit a short sexual screening history as part of a medical history of menopausal females. Obtain interventions only if the patient is distressed about the problem. B Show 2 more 3. Medical management Vaginal lubricants and moisturizers: As per SOGC 2021 guidelines, consider offering vaginal lubricants and moisturizers for the treatment of vaginal atrophy related to menopause. B As per SOGC 2021 guidelines, offer vaginal lubricants and/or vaginal moisturizers as first- line therapy for genitourinary syndrome of menopause, particularly if patient concerns are limited to vaginal dryness or dyspareunia. A As per ES 2015 guidelines: Consider offering vaginal lubricants in patients with insufficient vaginal secretions for comfortable sexual activity. C Consider offering a trial of vaginal moisturizers at least twice weekly in postmenopausal patients with symptoms of vulvovaginal atrophy. C As per SOGC 2014 guidelines, offer vaginal dilators, lubricants, and moisturizers in patients with signs or symptoms of vulvovaginal atrophy unable to use estrogens. B As per NAMS 2013 guidelines, offer nonhormonal lubricants and long-acting vaginal moisturizers (if indicated) as first-line therapy in patients with symptomatic vulvovaginal atrophy. A Local estrogen therapy: https://web.pathway.md/diseases/recLXBFI2uX50wJzY 2/6 6/29/23, 3:45 AM Vulvovaginal atrophy Pathway As per SOGC 2021 guidelines, consider offering vaginal estrogens and DHEA for the treatment of vaginal atrophy related to menopause. B As per SOGC 2021 guidelines, consider offering local vaginal estrogen, after consulting with the patient's oncologist, if local lubricants and moisturizers are ineffective in patients with breast cancer and symptomatic genitourinary syndrome of menopause. C As per SOGC 2021 guidelines: Offer vaginal estrogen, administered either as a cream, tablet, or sustained-release ring as second-line therapy for genitourinary syndrome of menopause. Do not use concomitant progestogen therapy as clinically significant systemic hormone absorption does not occur with low-dose therapy. A Offer vaginal DHEA ovules as another second-line therapy option for atrophic vaginal symptoms. A As per ES 2015 guidelines, offer low-dose vaginal estrogen therapy in patients without a history of hormone/estrogen-dependent cancers seeking relief from symptoms of genitourinary syndrome of menopause (including vulvovaginal atrophy) persisting despite using vaginal lubricants and moisturizers. B Show 3 more As per SOGC 2014 guidelines: Offer vaginal estrogen therapy (conjugated estrogen cream, intravaginal sustained-release estradiol ring, or low-dose estradiol vaginal tablets) in postmenopausal patients with vulvovaginal atrophy and sexual dysfunction. A Do not offer progestin co-therapy routinely for endometrial protection in patients receiving vaginal estrogen therapy in an appropriate dose. D As per NAMS 2013 guidelines: Offer low-dose vaginal estrogen therapy or systemic estrogen therapy in patients with moderate-to-severe vulvovaginal atrophy and in patients with milder vulvovaginal atrophy not responding to lubricants and moisturizers. Prefer low-dose vaginal estrogen therapy over systemic estrogen therapy if vulvovaginal atrophy is the only menopausal symptom. A Consider continuing vaginal estrogen therapy with appropriate clinical surveillance as long as bothersome symptoms are present. C As per AACE 2011 guidelines, consider offering transvaginal estrogen to provide topical effects with less systemic absorption. C Systemic estrogen therapy: As per SOGC 2021 guidelines, consider offering ospemifene for the treatment of vaginal atrophy related to menopause. B As per SOGC 2021 guidelines, offer oral selective estrogen receptor modulator ospemifene as second-line pharmacotherapy for atrophic vaginal symptoms. A As per ES 2015 guidelines: Consider offering a trial of ospemifene in postmenopausal patients with moderate-to- severe dyspareunia associated with vaginal atrophy, if not contraindicated. C https://web.pathway.md/diseases/recLXBFI2uX50wJzY 3/6 6/29/23, 3:45 AM Vulvovaginal atrophy Pathway Do not use ospemifene in patients with a history of breast cancer presenting with dyspareunia. D As per NAMS 2013 guidelines, offer systemic estrogen therapy in patients with moderate-to- severe vulvovaginal atrophy and in patients with milder vulvovaginal atrophy not responding to lubricants and moisturizers. Offer ospemifene for the management of dyspareunia. A Show 3 more As per AACE 2011 guidelines, consider offering menopausal hormone therapy during the perimenopause and early menopause for the treatment of vulvovaginal atrophy. B 4. Therapeutic procedures Vaginal laser therapy: insufficient evidence regarding the long-term use of intravaginal laser therapy to manage genitourinary syndrome of menopause outside of a clinical trial. I 5. Specific circumstances Patients with breast cancer: As per SOGC 2014 guidelines: Discuss quality-of-life considerations when considering the use of intravaginal estrogen therapy for severe vulvovaginal atrophy in patients with breast cancer, as well as the uncertainty regarding effects on breast cancer recurrence. B Discuss the uncertainty of risks associated with systemic hormone therapy after a diagnosis of breast cancer in patients seeking treatment for distressing symptoms (vasomotor symptoms or vulvovaginal atrophy). B As per NAMS 2013 guidelines, manage patients with a history of breast cancer depending on the patient's preference, need, understanding of potential risks, and consultation with her oncologist. B Patients with endometrial cancer: As per ES 2015 guidelines, consider using a shared decision-making approach to include the treating oncologist in discussing the use of low-dose vaginal estrogen in patients with a history of endometrial cancer presenting with symptomatic genitourinary syndrome of menopause (including vulvovaginal atrophy) and not responding to non-hormonal therapies. C As per NAMS 2013 guidelines: Consider obtaining surveillance transvaginal ultrasound or initiating intermittent progestogen therapy in patients at high risk of endometrial cancer or using a higher dose of vaginal estrogen therapy. Insufficient evidence to recommend routine annual endometrial surveillance in asymptomatic females using vaginal estrogen therapy. C Manage patients with a history of endometrial cancer depending on the patient's preference, need, understanding of potential risks, and consultation with her oncologist. B Patients with hormone-independent cancer: manage vulvovaginal atrophy in patients treated for non-hormone-dependent cancer similar to that for patients without a cancer history. B https://web.pathway.md/diseases/recLXBFI2uX50wJzY 4/6 6/29/23, 3:45 AM Vulvovaginal atrophy Pathway 6. Patient education General counseling: provide proactive education on vaginal health in postmenopausal females. B Clinical findings Symptoms Past medical history Dyspareunia Exposure to chemotherapy Dysuria Menopause Nocturia Pelvic radiation therapy Postcoital bleeding UTI Sexual dysfunction Gynecologic exam Urinary frequency Urinary incontinence Pale vaginal lining Urinary urgency Short vaginal canal Vaginal discharge Thin vaginal wall Vaginal itching Vaginal dryness Vaginal pain Vulvovaginal petechiae Past surgical history Oophorectomy Lab findings vaginal pH serum estradiol serum estrogen References 1. Shawna Johnston, C line Bouchard, Michel Fortier et al. Guideline No. 422b: Menopause and Genitourinary Health. J Obstet Gynaecol Can. 2021 Nov;43 11 1301 1307.e1. Open 2. Stuenkel CA, Davis SR, Gompel A et al. Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2015 Nov;100 11 3975 4011. Open 3. Wendy Wolfman, Yonah Krakowsky, Michel Fortier. Guideline No. 422d: Menopause and Sexuality. J Obstet Gynaecol Can. 2021 Nov;43 11 1334 1341.e1. Open 4. North American Menopause Society. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause. 2013 Sep;20 9 888 902. Open 5. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 141 management of menopausal symptoms. Obstet Gynecol. 2014 Jan;123 1 202 16. Open 6. Reid R, Abramson BL, Blake J et al. Managing Menopause. J Obstet Gynaecol Can. 2014 Sep;36 9 830 833. Open https://web.pathway.md/diseases/recLXBFI2uX50wJzY 5/6 6/29/23, 3:45 AM Vulvovaginal atrophy Pathway 7. Neil F Goodman, Rhoda H Cobin, Samara Beth Ginzburg et al. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the diagnosis and treatment of menopause. Endocr Pract. Nov-Dec 2011;17 Suppl 6 1 25. Open 8. van Schalkwyk J, Yudin MH, INFECTIOUS DISEASE COMMITTEE. Vulvovaginitis: screening for and management of trichomoniasis, vulvovaginal candidiasis, and bacterial vaginosis. J Obstet Gynaecol Can. 2015 Mar;37 3 266 274. Open https://web.pathway.md/diseases/recLXBFI2uX50wJzY 6/6