Management of vulvovaginal atrophy-related sexual dysfunction in postmenopausal women: an up-to-date review

Animal Models for the Study of Female Sexual Dysfunction

INTRODUCTION

Significant progress has been made in elucidating the physiological and pharmacological mechanisms of female sexual function through preclinical animal research. The continued development of animal models is vital for the understanding and treatment of the many diverse disorders that occur in women.

AIM

To provide an updated review of the experimental models evaluating female sexual function that may be useful for clinical translation.

METHODS

Review of English written, peer-reviewed literature, primarily from 2000 to 2012, that described studies on female sexual behavior related to motivation, arousal, physiological monitoring of genital function and urogenital pain.

MAIN OUTCOMES MEASURES

Analysis of supporting evidence for the suitability of the animal model to provide measurable indices related to desire, arousal, reward, orgasm, and pelvic pain.

RESULTS

The development of female animal models has provided important insights in the peripheral and central processes regulating sexual function. Behavioral models of sexual desire, motivation, and reward are well developed. Central arousal and orgasmic responses are less well understood, compared with the physiological changes associated with genital arousal. Models of nociception are useful for replicating symptoms and identifying the neurobiological pathways involved. While in some cases translation to women correlates with the findings in animals, the requirement of circulating hormones for sexual receptivity in rodents and the multifactorial nature of women's sexual function requires better designed studies and careful analysis. The current models have studied sexual dysfunction or pelvic pain in isolation; combining these aspects would help to elucidate interactions of the pathophysiology of pain and sexual dysfunction.

CONCLUSIONS

Basic research in animals has been vital for understanding the anatomy, neurobiology, and physiological mechanisms underlying sexual function and urogenital pain. These models are important for understanding the etiology of female sexual function and for future development of pharmacological treatments for sexual dysfunctions with or without pain. Marson L, Giamberardino MA, Costantini R, Czakanski P, and Wesselmann U. Animal models for the study of female sexual dysfunction. Sex Med Rev 2013;1:108-122.

Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly Quality Measures

The National Committee for Quality Assurance (NCQA) and the Pharmacy Quality Alliance (PQA) use the American Geriatrics Society (AGS) Beers Criteria to designate the quality measure Use of High-Risk Medications in the Elderly (HRM). The Centers for Medicare and Medicaid Services (CMS) use the HRM measure to monitor and evaluate the quality of care provided to Medicare beneficiaries. NCQA additionally uses the AGS Beers Criteria to designate the quality measure Potentially Harmful Drug-Disease Interactions in the Elderly. Medications included in these measures may be harmful to elderly adults and negatively affect a healthcare plan's quality ratings. Prescribers, pharmacists, patients, and healthcare plans may benefit from evidence-based alternative medication treatments to avoid these problems. Therefore the goal of this work was to develop a list of alternative medications to those included in the two measures. The authors conducted a comprehensive literature review from 2000 to 2015 and a search of their personal files. From the evidence, they prepared a list of drug-therapy alternatives with supporting references. A reference list of nonpharmacological approaches was also provided when appropriate. NCQA, PQA, the 2015 AGS Beers Criteria panel, and the Executive Committee of the AGS reviewed the drug therapy alternatives and nonpharmacological approaches. Recommendations by these groups were incorporated into the final list of alternatives. The final product of drug-therapy alternatives to medications included in the two quality measures and some nonpharmacological resources will be useful to health professionals, consumers, payers, and health systems that care for older adults.

Menopause and Sexuality

Sexuality is an important component in the lives of menopausal women. Despite the importance of sexual function in menopausal women, sexual dysfunction increases with age. Age-related decline in sexual function may significantly reduce quality of life, making recognition of sexual dysfunction by physicians important for getting menopausal women effective care. Sexual dysfunction can result from multiple etiologies including psychosocial factors, medication side effects, vulvovaginal atrophy, chronic illness, or hypoactive sexual desire disorder. Discovering the etiology and identifying modifiable factors of the sexual function will help define appropriate treatment.

The Recent Review of the Genitourinary Syndrome of Menopause

The genitourinary syndrome of menopause (GSM) is a new term that describes various menopausal symptoms and signs including not only genital symptoms (dryness, burning, and irritation), and sexual symptoms (lack of lubrication, discomfort or pain, and impaired function, but also urinary symptoms (urgency, dysuria, and recurrent urinary tract infections). The terms vulvovaginal atrophy and atrophic vaginitis, which were generally used until recently, had a limitation because they did not cover the full spectrum of symptoms and did not imply that the symptoms are related to a decreased estrogen level in menopause. Since the GSM may have a profound negative impact on the quality of life of postmenopausal women, women should be made aware of these problems and treated with an appropriate effective therapy. Thus, in this review we introduce new terminology and discuss the importance of comprehension of GSM and the necessity of active treatment of this syndrome in postmenopausal women.

Genitourinary syndrome of menopause and the use of laser therapy

Genitourinary syndrome of menopause is a common condition that left untreated can progress and negatively affect quality of life and sexual function. Laser therapy has a therapeutic role for several gynecologic conditions and most recently has gained interest as a non-hormonal treatment for genitourinary syndrome of menopause (GSM). The laser is well tolerated and may increase thickness of the squamous epithelium and improve vascularity of the vagina. These morphological changes presumably alleviate symptoms of dryness, dyspareunia, and irritation. However, the duration of therapeutic effects and safety of repeated applications at this point is not clear. Further research is needed in the form of controlled studies of the laser and other non-hormonal GSM therapies. The objective of this paper is to review the existing literature describing laser therapy for GSM.

Helping Women Understand Treatment Options for Vulvar and Vaginal Atrophy

Vulvar and vaginal atrophy (VVA) is a common and progressive medical condition in postmenopausal women. The REVIVE (REal Women's VIews of Treatment Options for Menopausal Vaginal ChangEs) survey assessed knowledge about VVA and its impact in 3,046 postmenopausal U.S. women, and recorded women's attitudes about their interactions with health care providers and about available treatments. REVIVE identified poor disease awareness and understanding among women, failure of health care professionals to evaluate women for VVA signs and symptoms, low treatment rates and concerns about the safety and efficacy of available therapies. Strategies to address these needs include proactive screening, education for women and clinicians about VVA and recommendations for treatment and follow-up.

Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society

BACKGROUND

In 2012, the Board of Directors of the International Society for the Study of Women's Sexual Health (ISSWSH) and the Board of Trustees of The North American Menopause Society (NAMS) acknowledged the need to review current terminology associated with genitourinary tract symptoms related to menopause.

METHODS

The 2 societies cosponsored a terminology consensus conference, which was held in May 2013.

RESULTS AND CONCLUSIONS

Members of the consensus conference agreed that the term genitourinary syndrome of menopause (GSM) is a medically more accurate, all-encompassing, and publicly acceptable term than vulvovaginal atrophy. GSM is defined as a collection of symptoms and signs associated with a decrease in estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra and bladder. The syndrome may include but is not limited to genital symptoms of dryness, burning, and irritation; sexual symptoms of lack of lubrication, discomfort or pain, and impaired function; and urinary symptoms of urgency, dysuria and recurrent urinary tract infections. Women may present with some or all of the signs and symptoms, which must be bothersome and should not be better accounted for by another diagnosis. The term was presented and discussed at the annual meeting of each society. The respective Boards of NAMS and ISSWSH formally endorsed the new terminology--genitourinary syndrome of menopause (GSM)--in 2014.

Atrophic vaginitis in breast cancer survivors: a difficult survivorship issue

Management of breast cancer includes systematic therapies including chemotherapy and endocrine therapy can lead to a variety of symptoms that can impair the quality of life of many breast cancer survivors. Atrophic vaginitis, caused by decreased levels of circulating estrogen to urinary and vaginal receptors, is commonly experienced by this group. Chemotherapy induced ovarian failure and endocrine therapies including aromatase inhibitors and selective estrogen receptor modulators can trigger the onset of atrophic vaginitis or exacerbate existing symptoms. Symptoms of atrophic vaginitis include vaginal dryness, dyspareunia, and irritation of genital skin, pruritus, burning, vaginal discharge, and soreness. The diagnosis of atrophic vaginitis is confirmed through patient-reported symptoms and gynecological examination of external structures, introitus, and vaginal mucosa. Lifestyle modifications can be helpful but are usually insufficient to significantly improve symptoms. Non-hormonal vaginal therapies may provide additional relief by increasing vaginal moisture and fluid. Systemic estrogen therapy is contraindicated in breast cancer survivors. Continued investigations of various treatments for atrophic vaginitis are necessary. Local estrogen-based therapies, DHEA, testosterone, and pH-balanced gels continue to be evaluated in ongoing studies. Definitive results are needed pertaining to the safety of topical estrogens in breast cancer survivors.

Association between the vaginal microbiota, menopause status, and signs of vulvovaginal atrophy

OBJECTIVE

The vaginal microbiota helps protect the female genital tract from disease. We sought to describe the composition of the vaginal microbiota in premenopausal, perimenopausal, and postmenopausal women and to explore the association between the microbiota and vulvovaginal atrophy (VVA).

METHODS

Eighty-seven women (aged 35-60 y) were classified as premenopausal (n = 30), perimenopausal (n = 29), or postmenopausal (n = 28) according to Stages of Reproductive Aging Workshop guidelines. Midvaginal bacterial community composition was characterized by 16S ribosomal RNA gene analysis.

RESULTS

Bacterial communities clustered into six community state types (CSTs), of which four were dominated by Lactobacillus crispatus, Lactobacillus gasseri, Lactobacillus iners, or Lactobacillus jensenii, and two (CST IV-A and CST IV-B) had low relative abundance of Lactobacillus. CST IV-A was characterized by Streptococcus and Prevotella, whereas CST IV-B was characterized by Atopobium. There were significant associations between menopause stage and CST (P = 0.004) and between VVA and CST (P = 0.002). Perimenopausal women were more likely to be classified as CST IV-A or L. gasseri CST, whereas postmenopausal women were often classified as CST IV-A. CSTs dominated by L. crispatus and L. iners were more prevalent in premenopausal women. Nineteen participants had signs of mild or moderate VVA. Compared with women with no VVA, the vaginal microbiota of women with mild or moderate atrophy had 25-fold greater odds of being classified as CST IV-A versus L. crispatus CST (adjusted odds ratio, 25.89; 95% credible interval, 2.98-406.79).

CONCLUSIONS

A distinct bacterial community state (CST IV-A) with a low relative abundance of Lactobacillus is associated with VVA. Future studies recruiting a larger number of women are needed to replicate the findings. This study provides an impetus for future longitudinal studies designed to manage, modulate, and restore vaginal microbiota homeostasis, which would provide stronger evidence for a causal relationship with VVA and ultimately improve the treatment and prevention of atrophic vaginitis in menopause.

Symptoms: Menopause, Infertility, and Sexual Health

By 2022, the number of survivors is expected to grow to nearly 18 million. Therefore, addressing acute and chronic negative sequelae of a cancer diagnosis and its treatments becomes a health imperative. For women with a history of breast cancer, one of the common goals of treatment and prevention of recurrence is to reduce circulating concentrations of estradiol, especially in women with hormone receptor positive breast cancer. Hormone deprivation after a diagnosis of breast cancer impacts physiological targets other than in the breast tissue and can result in unwanted side effects, all of which can negatively impact quality of life and function and cause distress. Symptoms that are most strongly linked by evidence to hormone changes after cancer diagnosis and treatment include hot flashes, night sweats, sleep changes, fatigue, mood changes, and diminishing sexual function, including vaginal atrophy (decreased arousal, dryness and dyspareunia), infertility, decreased desire and negative self-image. Weight gain and resulting body image changes are often concomitants of the abrupt onset of treatment-induced menopause. The purpose of this chapter is to briefly review what is known about the advent of premature menopause in women treated for breast cancer, menopausal symptoms that are exacerbated by endocrine treatments for breast cancer, and the associated concerns of hot flashes and related menopausal symptoms, sexual health and fertility issues. We will discuss limitations in the current research and propose strategies that address current limitations in order to move the science forward.

Clinical effects of selective estrogen receptor modulators on vulvar and vaginal atrophy

OBJECTIVE

Vaginal estrogen therapy at the lowest effective dose is generally recommended for the treatment of vulvar and vaginal atrophy (VVA), but not all women are candidates. Selective estrogen receptor modulators (SERMs) aim to elicit specific positive effects on targeted tissues with neutral or minimal negative effects on other tissues. This review compares the vaginal effects of currently available and investigational SERMs.

METHODS

Relevant English-language articles published between 1980 and 2012 were identified through the PubMed database (search string "[Selective Estrogen Receptor Modulator OR SERM] AND [Vulvar OR Vaginal] AND Atrophy"), article reference lists, and EMBASE searches for individual SERMs. Both authors reviewed all articles, which formed the basis of this narrative literature review.

RESULTS

Activity profiles of SERMs in various tissues are distinct. Tamoxifen and arzoxifene have no specific positive vaginal effects but have reported variable or adverse gynecologic effects. Raloxifene does not improve VVA but can be used safely in combination with vaginal estrogen. Bazedoxifene has no demonstrated efficacy for VVA but, in combination with oral conjugated equine estrogens, improves the signs and symptoms of VVA. SERMs with positive vaginal effects (such as improvement in the vaginal maturation index, reduced vaginal pH, and improvement in the signs and symptoms of VVA) on postmenopausal symptomatic women include lasofoxifene (clinical development on hold) and ospemifene, which was recently approved for the treatment of VVA-related dyspareunia, with a class effect warning of potential venous thrombosis risk.

CONCLUSIONS

SERMs that specifically target the pathophysiology underlying VVA may provide an alternative to vaginal or systemic estrogen therapy.

Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society

INTRODUCTION

The terminology for the genitourinary tract symptoms related to menopause was vulvovaginal atrophy, which does not accurately describe the symptoms nor is a term that resonates well with patients.

AIM

In 2012, the Board of Directors of the International Society for the Study of Women's Sexual Health (ISSWSH) and the Board of Trustees of The North American Menopause Society (NAMS) acknowledged the need to review current terminology associated with genitourinary tract symptoms related to menopause.

METHODS

The two societies cosponsored a terminology consensus conference, which was held in May 2013.

MAIN OUTCOME MEASURE

The development of a new terminology that more accurately described the genitourinary tract symptoms related to menopause.

RESULTS

Members of the consensus conference agreed that the term genitourinary syndrome of menopause (GSM) is a medically more accurate, all-encompassing, and publicly acceptable term than vulvovaginal atrophy. GSM is defined as a collection of symptoms and signs associated with a decrease in estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra, and bladder. The syndrome may include but is not limited to genital symptoms of dryness, burning, and irritation; sexual symptoms of lack of lubrication, discomfort or pain, and impaired function; and urinary symptoms of urgency, dysuria, and recurrent urinary tract infections. Women may present with some or all of the signs and symptoms, which must be bothersome and should not be better accounted for by another diagnosis.

CONCLUSION

The term GSM was presented and discussed at the annual meeting of each society. The respective Boards of NAMS and ISSWSH formally endorsed the new terminology--genitourinary syndrome of menopause--in 2014.

Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and The North American Menopause Society

BACKGROUND

In 2012, the Board of Directors of the International Society for the Study of Women's Sexual Health (ISSWSH) and the Board of Trustees of The North American Menopause Society (NAMS) acknowledged the need to review current terminology associated with genitourinary tract symptoms related to menopause.

METHODS

The two societies cosponsored a terminology consensus conference, which was held in May 2013.

RESULTS AND CONCLUSION

Members of the consensus conference agreed that the term genitourinary syndrome of menopause (GSM) is a medically more accurate, all-encompassing, and publicly acceptable term than vulvovaginal atrophy. GSM is defined as a collection of symptoms and signs associated with a decrease in estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra and bladder. The syndrome may include but is not limited to genital symptoms of dryness, burning, and irritation; sexual symptoms of lack of lubrication, discomfort or pain, and impaired function; and urinary symptoms of urgency, dysuria and recurrent urinary tract infections. Women may present with some or all of the signs and symptoms, which must be bothersome and should not be better accounted for by another diagnosis. The term was presented and discussed at the annual meeting of each society. The respective Boards of NAMS and ISSWSH formally endorsed the new terminology - genitourinary syndrome of menopause (GSM) - in 2014.

Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society

BACKGROUND

In 2012, the Board of Directors of the International Society for the Study of Women's Sexual Health (ISSWSH) and the Board of Trustees of The North American Menopause Society (NAMS) acknowledged the need to review current terminology associated with genitourinary tract symptoms related to menopause.

METHODS

The 2 societies cosponsored a terminology consensus conference, which was held in May 2013.

RESULTS AND CONCLUSION

Members of the consensus conference agreed that the term genitourinary syndrome of menopause (GSM) is a medically more accurate, all-encompassing, and publicly acceptable term than vulvovaginal atrophy. GSM is defined as a collection of symptoms and signs associated with a decrease in estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra and bladder. The syndrome may include but is not limited to genital symptoms of dryness, burning, and irritation; sexual symptoms of lack of lubrication, discomfort or pain, and impaired function; and urinary symptoms of urgency, dysuria and recurrent urinary tract infections. Women may present with some or all of the signs and symptoms, which must be bothersome and should not be better accounted for by another diagnosis. The term was presented and discussed at the annual meeting of each society. The respective Boards of NAMS and ISSWSH formally endorsed the new terminology--genitourinary syndrome of menopause (GSM)--in 2014.

Complication of a 2-mg estradiol vaginal ring: fibrotic vaginal adhesion

OBJECTIVE

This work aims to review a novel case of a retained 2-mg estradiol vaginal ring used to treat postmenopausal urogenital atrophy. The ring was found adhered to the posterior fornix by a fibrotic band. This is the first reported case in the medical literature.

METHODS

We describe the case of a postmenopausal woman experiencing symptoms of urogenital atrophy. Factors predisposing her to this complication (such as inconsistent use of other forms of vaginal estradiol, initial incorrect use of the ring with two rings in place, and subsequent vaginal stenosis and irritation requiring vaginal dilator therapy at one point in her treatment course) were analyzed. A review of the medical literature was performed to examine the safety profile of estradiol vaginal rings used to treat urogenital atrophy and to investigate the incidence of complications.

RESULTS

Two-milligram estradiol vaginal rings treat symptoms of urogenital atrophy by delivering a constant supply of estradiol to the vaginal epithelium. The ring has been shown to be as safe and effective as other forms of vaginal estrogen. Vaginal irritation is a known complication of 2-mg estradiol vaginal rings and other vaginal implants; however, none of the randomized controlled trials that have compared the ring to other vaginal estrogen forms have reported adherence of the ring to the vaginal epithelium.

CONCLUSIONS

Providers should be aware of the possibility of ring adherence to the vaginal epithelium and should exercise caution in using the 2-mg estradiol vaginal ring in women with significant vaginal stenosis or irritation.

Management of Vaginal Atrophy: Implications from the REVIVE Survey

Vulvar and vaginal atrophy (VVA) is a chronic and progressive medical condition common in postmenopausal women. Symptoms of VVA such as dyspareunia, vaginal dryness, irritation, and itching can negatively impact sexual function and quality of life. The REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey assessed knowledge about VVA and recorded attitudes about interactions with healthcare providers (HCPs) and available treatment options for VVA. The REVIVE survey identified unmet needs of women with VVA symptoms such as poor understanding of the condition, poor communication with HCPs despite the presence of vaginal symptoms, and concerns about the safety, convenience, and efficacy of available VVA treatments. HCPs can address these unmet needs by proactively identifying patients with VVA and educating them about the condition as well as discussing treatment preferences and available therapies for VVA.

Etiology, diagnosis, and clinical management of vulvodynia

Chronic vulvar pain or discomfort for which no obvious etiology can be found, ie, vulvodynia, can affect up to 16% of women. It may affect girls and women across all age groups and ethnicities. Vulvodynia is a significant burden to society, the health care system, the affected woman, and her intimate partner. The etiology is multifactorial and may involve local injury or inflammation, and peripheral and or central sensitization of the nervous system. An approach to the diagnosis and management of a woman presenting with chronic vulvar pain should address the biological, psychological, and social/interpersonal factors that contribute to her illness. The gynecologist has a key role in excluding other causes for vulvar pain, screening for psychosexual and pelvic floor dysfunction, and collaborating with other health care providers to manage a woman's pain. An important component of treatment is patient education regarding the pathogenesis of the pain and the negative impact of experiencing pain on a woman's overall quality of life. An individualized, holistic, and often multidisciplinary approach is needed to effectively manage the woman's pain and pain-related distress.

Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society

OBJECTIVE

To update and expand the previous position statement of The North American Menopause Society (NAMS) on the management of symptomatic vulvovaginal atrophy (VVA) in postmenopausal women.

METHODS

NAMS searched PubMed for medical literature on VVA published since their 2007 position statement on the role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women. A panel of acknowledged experts in the field of genitourinary health reviewed the literature to evaluate new evidence on local estrogen as well as on other management options available or in development for symptomatic VVA. The panel's conclusions and recommendations were reviewed and approved by the NAMS Board of Trustees.

RESULTS

Symptomatic VVA can significantly impair the quality of life (QOL) of postmenopausal women and may be underdiagnosed. In most cases, it can be managed successfully. A number of over-the-counter and government-approved prescription therapies available in the United States and Canada demonstrate effectiveness, depending on the severity of VVA symptoms. These include vaginal lubricants and moisturizers, vaginal estrogen, hormone therapy, and the selective estrogen-receptor modulator ospemifene (indicated for dyspareunia). Long-term studies on the endometrial safety of local estrogen and ospemifene are lacking. Changes in the vaginal microbiome have various effects on symptoms.

CONCLUSIONS

Clinicians can improve the sexual health and QOL of postmenopausal women by educating women about, diagnosing, and appropriately managing symptomatic VVA. Choice of therapy depends on the severity of symptoms, the effectiveness and safety of therapy for the individual patient, and patient preference. Estrogen therapy is the most effective treatment for moderate to severe symptoms, although a direct comparison of estrogen and ospemifene is not available. Nonhormonal therapies available without a prescription provide sufficient relief for most women with mild symptoms. When low-dose estrogen is administered locally, a progestogen is not indicated for women without a uterus and generally is not indicated for women with an intact uterus. However, endometrial safety has not been studied in clinical trials beyond 1 year. There are insufficient data to confirm the safety of local estrogen in women with breast cancer; management of VVA should take the woman's needs and the recommendation of her oncologist into consideration. Research on the vaginal microbiome may lead to other therapies in the future.

Ospemifene in the treatment of vulvovaginal atrophy

OBJECTIVE

To review the pharmacology, efficacy, and safety of ospemifene in the management of dyspareunia.

DATA SOURCES

Literature was sought using PubMed (1966-January 2014) and EMBASE (1973-January 2014). Search terms included ospemifene, FC-1271a, dyspareunia, vulvovaginal atrophy, and vaginal atrophy.

STUDY SELECTION AND DATA EXTRACTION

All studies, including studies on humans, published in English with data assessing the efficacy and safety of ospemifene in the management of dyspareunia were evaluated.

DATA SYNTHESIS

Ospemifene is a new oral estrogen receptor agonist/antagonist indicated for moderate to severe dyspareunia. Clinical trials evaluating efficacy have shown a significant improvement in superficial cells, parabasal cells, vaginal pH, vaginal dryness, and dyspareunia. The most frequently reported adverse drug reactions in the clinical trials included hot flashes, vaginal discharge, muscle spasms, and hyperhidrosis. Similar to systemic estrogen, boxed warnings with ospemifene include risk for thromboembolism and cerebrovascular disease. Additionally, patients with a uterus still need to use a progestogen with ospemifene to reduce the risk of hyperplasia.

CONCLUSIONS

Ospemifene has been effective in improving symptoms of vulvovaginal atrophy when compared with placebo; however, no studies comparing ospemifene with estrogen products exist. Additional clinical trials are needed to evaluate the efficacy and safety in specialty populations, and long-term safety data are needed to assess the potential for serious adverse events. With the risks being similar to that for systemic estrogen therapy, ospemifene appears to be an alternative agent to estrogen therapy but does not have any advantages over estrogen.

Long-term safety of ospemifene (52-week extension) in the treatment of vulvar and vaginal atrophy in hysterectomized postmenopausal women

OBJECTIVE

To examine the long-term safety of oral ospemifene, a non-estrogen tissue-selective estrogen agonist/antagonist, for the treatment of moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy (VVA) due to menopause.

STUDY DESIGN

This multicenter, long-term, open-label, safety extension study was conducted in women without a uterus aged 40-80 years (N=301) who received oral ospemifene 60 mg/day for 52 weeks. Participants either continued their 60-mg/day ospemifene dose from the initial 12-week pivotal efficacy study or switched from blinded placebo or ospemifene 30 mg/day to open-label ospemifene 60 mg/day. The 52-week open-label extension period plus initial 12-week treatment period totaled up to 64 weeks of ospemifene exposure. A 4-week posttreatment follow-up ensued (68 weeks total).

MAIN OUTCOME MEASURES

Safety assessments included adverse events, laboratory studies, physical and gynecologic examination, vital signs, breast palpation, and mammography.

RESULTS

Most treatment-emergent adverse events (TEAEs) during the extension study were mild or moderate in severity. The most common TEAE related to study drug was hot flushes (10%; leading to discontinuation for 2% of patients). One serious TEAE, a non-ST-elevation myocardial infarction in a patient with pre-existing cardiac disease, was considered possibly related to study medication. One mild breast-related TEAE, considered unrelated to study drug, was ongoing at study completion. There were no instances of pelvic organ prolapse, incontinence, venous thromboembolism, fractures, breast cancers or death. No clinically significant adverse changes were observed in other safety parameters.

CONCLUSIONS

Ospemifene is clinically safe and generally well tolerated in postmenopausal patients with dyspareunia, a symptom of VVA.

Tissue selectivity of ospemifene: pharmacologic profile and clinical implications

The multifactorial consequences of menopausal estrogen deficiency affect numerous tissues throughout the body. Supplemental hormonal therapies carry the burden of a risk/benefit ratio that must be highly individualized. Selective estrogen receptor modulators (SERMs) are estrogen receptor (ER) agonist/antagonists designed to induce benefits comparable with estrogen while minimizing adverse effects. Here, we review the estrogen agonist/antagonist profile of ospemifene, a novel triphenylethylene derivative recently approved to treat dyspareunia, a symptom of vulvar and vaginal atrophy (VVA) due to menopause, both preclinically and clinically. Ospemifene binds ERα and ERβ with approximately equal affinities. In preclinical models, ospemifene increased vaginal and uterine epithelial thickness and mucification to the same extent as estrogen. Ospemifene did not induce endometrial hyperplasia in animal models; there also was no stimulatory effect on endometrial cells. In rat and human mammary cells in vitro, ospemifene evokes a dose-dependent inhibition on estrogen-induced cell responses and cell proliferation, supporting an antiestrogenic effect in breast. In contrast, ospemifene has an estrogenic effect on bone, as seen by improved bone mineral density, strength, mass, and histomorphometry in preclinical models, consistent with improvements in markers of bone resorption and formation in postmenopausal women. Based on the preclinical evidence, ospemifene has beneficial estrogen-like effects on the vaginal epithelium, preliminary evidence to support a neutral endometrial profile, antiproliferative effects in breast, and estrogenic effects in bone. Taken together, especially regarding estrogen-like effects on the vaginal epithelium, ospemifene presents a profile of tissue-specific effects that appear novel among available SERMs and well-suited for the treatment of VVA.

Profile of ospemifene in the breast

Vulvar and vaginal atrophy (VVA) is a chronic, progressive medical condition prevalent among postmenopausal women, which produces symptoms such as dyspareunia, vaginal dryness, and vaginal irritation. Currently, the only prescription options are systemic and vaginal estrogen therapies that may be limited by concerns about long-term safety and breast cancer risk. Ospemifene is a tissue-selective estrogen agonist/antagonist (a selective estrogen receptor modulator) recently approved by the US Food and Drug Administration for treatment of dyspareunia, a symptom of VVA, due to menopause. Ospemifene, the first nonestrogen oral treatment for this indication, may provide an alternative to treatment with estrogen. Animal models with ospemifene suggest an inhibitory effect on growth of malignant breast tissue, but animal data cannot necessarily be extrapolated to humans. Clinical trials, including 3 long-term studies assessing the overall safety of ospemifene, support that ospemifene is generally well tolerated, with beneficial effects on the vagina, neutral effects on the breast, and minimal effects on the endometrium.

Prevalence of vasomotor, psychological, psychosomatic and sexual symptoms in perimenopausal and recently postmenopausal Greek women: association with demographic, life-style and hormonal factors

AIM

To assess the prevalence of climacteric symptoms and their association with demographic, life-style and hormonal parameters in Greek peri- and recently postmenopausal women.

METHODS

1025 Greek women who were either perimenopausal or within their first 5 postmenopausal years participated in this cross-sectional observational study. Menopausal symptoms were assessed by the Greene Climacteric Scale and were tested for associations with demographic, anthropometric, life-style and hormonal parameters.

RESULTS

29.8% Of the women reported moderate to severe menopausal symptoms. More specifically, 39.2% reported vasomotor, 21.3% psychological, 6.3% psychosomatic and 34.5% sexual symptoms. Years since menopause (r = 0.13, p < 0.01), waist circumference (r = 0.11, p < 0.05) as well as serum FSH, LH and estradiol (r = 0.15, r = 0.118, r = -0.157; p < 0.01) correlated with the intensity of menopausal symptoms. In the multivariate analysis years since menopause and serum estradiol were the only significant predictors of menopausal symptoms (b = -0.158 and b = -0.198, p < 0.001, respectively), explaining though only 4.8% of the variance.

CONCLUSION

One out of three Greek women has moderate to severe climacteric symptoms during the menopause transition or the first postmenopausal years. This frequency is comparable to other White populations. Menopausal age and endogenous estrogens are significant predictors of climacteric symptoms.

Non-hormonal topical treatment of vulvovaginal atrophy: an up-to-date overview

Vulvovaginal atrophy-related symptoms exert a negative impact on the quality of life of up to 50% of postmenopausal women. Many of them decline to use topical vaginal estrogen, which is the standard effective therapy, due to the adverse publicity over recent years, and seek for alternatives. Further, there are no safety studies to support the use of topical vaginal estrogen in breast cancer survivors, and it is considered as contraindicated by many health-care professionals. Vaginal moisturizers and lubricants as well as regular sexual activity may be helpful to such women. Vaginal moisturizers may have an equivalent efficacy to topical vaginal estrogen and should be offered to women wishing to avoid the use of hormonal therapy. Lubricants are usually used during sexual intercourse to provide temporary relief from vaginal dryness and dyspareunia; however, they have no long-term therapeutic effects. We provide in this systematic review up-to-date information, for women and health-care professionals, about the use, safety and efficacy of the available vaginal moisturizers and lubricants.