Ultra-low-dose estriol and lactobacilli in the local treatment of postmenopausal vaginal atrophy

The Postmenopausal Vaginal Microbiome and Genitourinary Syndrome of Menopause

This review summarizes our current understanding of associations of the postmenopausal vaginal microbiome with genitourinary syndrome of menopause. We review the normal postmenopausal microbiota, examine the association of the microbiome with vulvovaginal symptoms, describe microbial communities associated with physical and laboratory findings, and report the impact of different treatments for genitourinary syndrome of menopause on microbiota and symptom improvement. Postmenopausal vaginal symptoms have an underlying pathophysiology that has not been fully elucidated. Estrogen treatment may not be sufficient to relieve symptoms of vaginal discomfort in all postmenopausal individuals. In addition, other interventions targeted at changing the microbiota or pH do not consistently improve symptom severity.

Herbal Treatment of Female Urogenital Atrophy: A Retrospective Cohort Analysis

INTRODUCTION

Urogenital atrophy and its sequelae, particularly genital dryness, urological problems, and pain on genital touching, are common medical problems for menopausal women and women undergoing antihormonal cancer treatment. To meet the requirements for a nonhormonal local treatment, a compounded herbal preparation was developed as a vaginal ovule (Dioscorea comp. ovulum), and the efficacy and applicability of this herbal treatment were investigated.

METHODS

This was a retrospective chart review of patients' records. The study was approved by the Ethics Committee of the Canton of Zurich (project number BASEC 2016-01982). Between 2007 and 2011, patients with urogenital atrophy and related symptoms, who wanted to initiate herbal treatment, were asked for consent to be interviewed (4-point rating scale) and examined gynecologically with photo documentation of their vaginal discharge. A total of 26 patients met the enrollment criteria and consented to the procedure. The first 8 weeks consisted of a daily application of low-dose Dioscorea comp. ovulum followed by high-dose Dioscorea comp. ovule twice weekly for at least 3 months.

RESULT

A total of 23 patients completed the trial. Of the 19 patients in the subgroup with an atrophic vaginal maturation index (VMI), 16 achieved a eutrophic VMI. Four patients began therapy with hypotrophy. There was a 96% decrease in complaints (22/23). The genital dryness score decreased from 1.80 to 0.25 points, urological problems from 2.38 to 0.85 points, and pain on genital touching from 1.70 to 0.60 points. Application, tolerability, and medical safety of the formula were good.

CONCLUSION

The phytotherapeutic compounded preparation Dioscorea comp. ovule (Dioscorea villosa, Glycine max, Salvia officinalis) is suitable for the treatment of urogenital atrophy and its sequelae.

Hintergrund

Urogenitale Atrophie und ihre Folgeerscheinungen, insbesondere genitale Trockenheit, urologische Probleme und schmerzhafte genitale Berührungen, sind ein häufiges medizinisches Problem bei menopausalen Frauen und Frauen unter antihormoneller Krebstherapie. Um den Bedarf an einer nicht-hormonellen lokalen Behandlung zu decken, wurde ein pflanzliches Präparat in Form eines Vaginal-Ovulum (Dioscorea comp. Ovulum) entwickelt. Wirksamkeit und Anwendbarkeit dieser pflanzlichen Behandlung werden untersucht.

Patientinnen und Methoden

Es handelt sich um eine retrospektive Analyse. Das Studienprotokoll wurde von der Ethikkommission des Kantons Zürich genehmigt (Projekt Nummer BASEC 2016-01982). Zwischen 2007 und 2011 wurden geeignete Patientinnen mit urogenitaler Atrophie und assoziierten Beschwerden, die mit einer pflanzlichen Behandlung beginnen wollten, um ihr Einverständnis zu einer Befragung (4-Punkte-Score) und gynäkologischen Untersuchungen mit Fotodokumentation des Vaginalausflusses (Nativpräparat) gebeten. 26 Patientinnen erfüllten die Kriterien und erklärten sich mit dem Verfahren einverstanden.

Behandlung

Nach einer täglichen Anwendung eines niederdosierten Dioscorea comp. Ovulum folgte eine zweimal wöchentliche Anwendung des höher dosierten Dioscorea comp. Ovulum für mindestens 3 Monate.

Ergebnisse

Insgesamt 23 Patientinnen schlossen die Studie ab. 16 von 19 Patientinnen in der Untergruppe mit einem atrophen Vaginalen Maturations-Index (VMI) erreichten ein eutrophes Vaginalepithel. Vier Patientinnen begannen mit einer Hypotrophie. Ein Rückgang der Beschwerden wurde bei 96% (22 von 23) erreicht: Trockenheit im Genitalbereich ging von 1,80 auf 0,25 Score-Punkte zurück, urologische Probleme von 2,38 auf 0,85 Score-Punkte und schmerzhafte Berührungen im Genitalbereich von 1,70 auf 0,60 Score-Punkte. Anwendung, Verträglichkeit und medizinische Sicherheit der Magistralrezeptur sind gut.

Schlussfolgerung

Das phytotherapeutische Kombinationspräparat Dioscorea comp. Ovulum (Dioscorea villosa L., Glycine Max Merr., Salvia officinalis L.) eignet sich zur Behandlung der urogenitalen Atrophie und ihrer Folgeerscheinungen.

The role of probiotics in women's health: An update narrative review

Probiotics, live microorganisms that confer health benefits to the host when administered in adequate amounts, have gained considerable attention for their potential role in maintaining women's health. This overview summarizes key clinical findings on the beneficial effects of probiotics in various aspects of women's health. Probiotics, particularly Lactobacillus species, contribute to vaginal health by promoting a balanced vaginal microbiome to prevent infections and maintain an acidic environment. In gynecologic conditions, probiotics show potential in preventing and managing bacterial vaginosis, vulvovaginal candidiasis, and sexually transmitted infections. Probiotic supplementation has also been associated with improvements in metabolic parameters and menstrual irregularities in polycystic ovary syndrome patients. During pregnancy, probiotics may be helpful in reducing the risk of gestational diabetes, maternal group B streptococcal colonization, obstetric anemia, and postpartum mastitis. In recent years, the potential role of probiotics in the prevention and management of gynecologic cancer has gained attention. Further research is needed to better understand the specific mechanisms and determine the optimal Lactobacillus strains and dosages regimens for gynecologic cancer prevention and therapy. In conclusion, probiotics offer a non-invasive and cost-effective approach to support women's health and prevent obstetric and gynecologic complications.

The role of microbiota in the management of genitourinary syndrome of menopause

It is estimated that the 25-50% of women who are reaching menopause every year report symptoms related to the genitourinary syndrome of menopause (GSM). The symptoms are not due simply to lack of estrogen. One possible contributing cause of symptoms is the vaginal microbiota. The vaginal microbiota is a dynamic entity and plays a critical role in the pathogenic interplay of postmenopausal changes. Treatment of this syndrome depends on the severity and type of the symptoms and on the preferences and expectations of women. As there are many treatment options, therapy should be individualized. While new evidence on the role of Lactobacilli in premenopause is emerging, the role of Lactobacilli is still unclear in GSM and the impact of microbiota on vaginal health remains conflictual. However, some reports show promising data on the effect of probiotic therapy in menopause. In the literature there are few studies and small population samples on the role of an exclusive therapy with Lactobacilli and further data will be mandatory. Studies involving large numbers of patients and different intervention periods will be necessary to obtain evidence of the preventive and curative role of vaginal probiotics.

Effectiveness of vaginal estriol with lactobacilli on urinary symptoms in postmenopausal women: a randomized-controlled trial

OBJECTIVE

The aim of this study was to compare the effects of a vaginal tablet containing estriol (0.03 mg) plus lactobacilli (E3/L) with placebo on lower urinary tract symptoms (LUTS) in postmenopausal women (PMW).

METHODS

This randomized, double-blinded, placebo-controlled trial was conducted at Srinagarind Hospital in Khon Kaen, Thailand. PMW with at least one LUTS, such as frequency, nocturia, dysuria, urgency, or stress or urgency urinary incontinence, were recruited. Participants were randomly assigned to receive either an E3/L tablet or placebo, administered vaginally daily at bedtime for 2 weeks, then twice a week for another 2 weeks. Symptom severity score was assessed using a visual analog scale (VAS), and quality of life (QOL) was measured using the validated Thai version of the Incontinence Impact Questionnaire-Short Form. The primary outcome was proportion of the PMW with LUTS improvement. Secondary outcomes were symptom severity score, participant satisfaction, QOL, and adverse events. Relative risk and 95% confidence intervals (CIs) were calculated using the chi-square or Fisher's exact test. An independent-sample and paired t test were used to compare means.

RESULTS

Thirty-eight participants in each group completed the study. The proportion of PMW whose symptoms improved (both in terms of most bothersome symptom and overall) did not differ significantly between the two groups. Relative risk was 1.00 (95% CI, 0.74-1.36) and 0.90 (95% CI, 0.71-1.15), respectively. There were no differences in symptom severity score, participant satisfaction, or QOL.

CONCLUSIONS

A 1-month course of vaginal E3/L does not appear to improve LUTS in PMW.

Menopausal Changes in the Microbiome-A Review Focused on the Genitourinary Microbiome

A balanced interaction between the host and its microbiome is crucial to health. Research regarding the significance of the gut and vaginal microbiomes in female health is substantial. However, less data regarding the urinary microbiome are available. Interactions between the gut, vaginal, and urinary microbiomes are also currently being researched. Hormone-induced dysbiosis after menopause is believed to have effects on physical changes and health consequences. Postmenopausal changes in the gut microbiome are associated with increased short-chain fatty acids and hydrogen sulfide levels. Increased vaginal pH caused by reduced estrogen alters the vaginal microbiome, resulting in reduced levels of Lactobacillus. Such changes influence the vaginal structure and functions, contributing to the onset of genitourinary syndrome of menopause. A dysbiosis of the urinary microbiome is associated with urgency and urinary incontinence and also related to interstitial cystitis/bladder pain syndrome and neuropathic bladder. As these diseases commonly affect postmenopausal women, hormone-induced changes in the microbiome may play a role. Menopause increases the alpha diversity of the urinary microbiome and lowers the percentage of Lactobacillus in urine, and such changes precede recurrent cystitis. More research regarding the effects of changes in the urinary microbiome due to menopause on urinary tract diseases is needed.

Healthy Vaginal Microbiota and Influence of Probiotics Across the Female Life Span

Vaginal microbiota plays a central role in women’s health and reproduction. Vaginal microbiota is dynamic and shaped by hormonal shifts in each stage of a woman’s life from pre-puberty to postmenopause. Current research has mainly focused on vaginal bacterial and fungal members of the community and emphasized their role in disease. However, the impact of balanced vaginal microbiota on health and its interaction with the host is yet poorly understood. High abundance of vaginal lactobacilli is most strongly associated with health, but the concept of health may vary as vaginal dysbiosis may be asymptomatic. Furthermore, there is a lot of variation between ethnic groups in terms of dominating vaginal bacteria. Probiotic lactobacilli could be a safe and natural means to balance and maintain healthy vaginal microbiota. Research evidence is accumulating on their role in supporting women’s health throughout life. This review describes the current literature on vaginal microbiota, the major factors affecting its composition, and how the communities change in different life stages. Furthermore, we focused on reviewing available literature on probiotics and their impact on vaginal microbiota and health.

Connecting microbiome and menopause for healthy ageing

Understanding the interplay between the microbiome and menopause holds promise for new interventions to alleviate menopausal symptoms and improve quality of life for women.

Management of postmenopausal vulvovaginal atrophy: recommendations of the International Society for the Study of Vulvovaginal Disease

OBJECTIVE

To develop a best practice document for the management of postmenopausal vulvovaginal atrophy (VVA).

METHOD

Literature review carried out using clinical terms, treatments or interventions and comorbidity related to VVA.

RESULTS

There is a wide variety of interventions that may produce temporal benefits for VVA. However, there are significant limitations in scientific publications concerning VVA and related issues, including variable outcome evaluations, variability in population age range, and small, often underpowered sample sizes. Therapeutic management of VVA should follow a sequential order, considering women's age, symptoms, general health as well as treatment preference. Beneficial options include lubricants, moisturizers, vaginal estrogens (estradiol, estriol, promestriene, conjugated estrogens), androgens, prasterone, and laser application. In women with general menopausal symptoms who are candidates for systemic hormone therapy, the lowest effective dose should be used. Oral ospemifene is an effective selective estrogen receptor modulator to treat VVA. Systemic androgens have a limited role. Although laser procedures are commonly used, at this moment the International Society for the Study of Vulvovaginal Disease does not endorse its use out of the setting of clinical trials. Pelvic floor muscle training improves blood flow and elasticity of the vulvovaginal tissue. In breast cancer survivors, moisturizers and lubricants are first line therapy. However, limited absorption of low/ultra-low doses of estrogens suggests safety, especially in women under treatment with aromatase inhibitors. As clinical practice and available preparations vary between countries this text should be adapted to local circumstances.

CONCLUSIONS

There is a wide range of therapeutic options to individualize VVA treatments.

The Vaginal Microbiome: A Long Urogenital Colonization Throughout Woman Life

Vaginal microbial niche is a dynamic ecosystem, composed by more than 200 bacterial species which are influenced by genes, ethnic background and environmental-behavioral factors. Several lines of evidence have well documented that vaginal microbiome constantly changes over the course of woman’s life, so to exert an important impact on woman quality of life, from newborn to post-menopausal ages. This review aims at analyzing the role of vaginal microbiome in the maintenance of woman’s homeostasis and at tracking critical changes that commonly occur across woman’s lifetime. The role of hormone replacement therapy in the modulation of vaginal microbiome composition and in the improvement of vaginal wellness in postmenopausal women with decreasing levels of circulating estrogen is discussed.

Role of Vaginal Microbiota Dysbiosis in Gynecological Diseases and the Potential Interventions

Vaginal microbiota dysbiosis, characterized by the loss of Lactobacillus dominance and increase of microbial diversity, is closely related to gynecological diseases; thus, intervention on microbiota composition is significant and promising in the treatment of gynecological diseases. Currently, antibiotics and/or probiotics are the mainstay of treatment, which show favorable therapeutic effects but also bring problems such as drug resistance and high recurrence. In this review, we discuss the role of vaginal microbiota dysbiosis in various gynecological infectious and non-infectious diseases, as well as the current and potential interventions.

Effect of vaginal estrogen in postmenopausal women using vaginal pessary for pelvic organ prolapse treatment: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

Evidence and recommendations for the use of intravaginal estrogen for prevention of bacterial vaginosis and pessary-related complications are limited and controversial. We hypothesized that adding intravaginal estrogen to pessary use would decrease the incidence of bacterial vaginosis and other pessary-related complications.

METHODS

A single-center, open-label, randomized, parallel study was conducted between April 2018 and August 2020. Participants were randomized to either receive intravaginal estriol 0.03 mg plus Lactobacillus acidophilus 100 million viable cell vaginal tablets or have no treatment. The Amsel criteria, normal flora index, visual analog scale, Thai version of the ICIQ-VS (International Consultation on Incontinence Questionnaire-Vaginal symptoms) questionnaire, vaginal abrasions and vaginal bleeding were evaluated at entry and at 2- and 14-week follow-up.

RESULTS

Seventy-eight women were included and randomized to two groups (39 women per group). At 2-week follow-up, one participant in the intervention group and two participants in the control group were diagnosed with bacterial vaginosis (2.7% vs. 5.7%, p = 0.609). At 14-week follow-up, two participants in the intervention group and two participants in the control group were diagnosed with bacterial vaginosis (5.7% vs. 6.2%, p = 0.926). Normal flora index was significantly different at 2-week follow-up [8 (6.3) vs. 5 (6.0), p = 0.032]. There was no significant difference in the visual analog scale, Thai version of the ICIQ-VS, vaginal abrasions and vaginal bleeding between the 2- and 14-week follow-ups.

CONCLUSIONS

This study shows no benefit of intravaginal estrogen in reducing bacterial vaginosis, vaginal abrasions, vaginal bleeding and pain in postmenopausal women using a vaginal pessary for pelvic organ prolapse treatment.

[Genitourinary menopause syndrome. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]

INTRODUCTION

Genitourinary menopause syndrome (SGUM) is defined as a set of symptoms associated with a decrease of estrogen and other sexual steroids during menopause. The main symptoms are vulvovaginal (dryness, burning, itching), sexual (dyspareunia), and urinary (urinary infections, pollakiuria, nycturia, pain, urinary incontinence by urgenturia). SGUM leads to an alteration of the quality of life, and affects especially women's sexuality.

OBJECTIVE

The objective of this review was to elaborate guidelines for clinical practice regarding the management of SGUM in postmenopausal women, and in particular, in women with a history of breast cancer, treated or not with hormone therapy.

MATERIALS AND METHODS

A systematic review of the literature on SGUM management was conducted on Pubmed, Medline and Cochrane Library. Recommendations from international scholarly societies were also taken into account: International Menopause Society (IMS) https://www.imsociety.org, The North American Menopause Society (NAMS) https://www.menopause.org, Canadian Menopause Society https://www.sigmamenopause.com, European Menopause and Andropause Society (EMAS) https://www.emas-online.org, International Society for the Study of Women's Sexual Health (ISSWSH) https://www.isswsh.org.

RESULTS

Vaginal use of lubricants, moisturizers and hyaluronic acid improves the symptoms of SGUM and may be offered to all patients. For postmenopausal women, local estrogen will be preferred to the oral route because of their safety and efficacy on all symptoms of SGUM during low-dose use. Prasterone is a local treatment that can be proposed as an effective alternative for the management of dyspareunia and sexual function disorder. Current data on oral testosterone, tibolone, oral or transdermal DHEA and herbal medicine are currently limited. Ospemifène, which has shown a significant improvement in sexual symptoms, is not currently marketed in France. In the particular case of women with a history of breast cancer, non-hormonal regimens are a first-line therapy. Current data on the risk of breast cancer recurrence when administering low-dose local estrogen are reassuring but do not support a conclusion that this treatment is safe.

CONCLUSION

SGUM is a common symptom that can affect the quality of life of postmenopausal women. A treatment should be systematically proposed. Local non-hormonal treatment may be offered in all women. Local low-dose estrogen therapy and Prasterone has shown an interest in the management of symptoms. In women before a history of breast cancer, local non-hormonal treatment should be offered first-line. The safety of low-dose local estrogen therapy and Prasterone cannot be established at this time. Other alternatives exist but are not currently recommended in France due to lack of data.

Variation in outcome reporting and measurement tools in clinical trials of treatments for genitourinary symptoms in peri- and postmenopausal women: a systematic review

IMPORTANCE

Genitourinary symptoms affect 40% to 60% of postmenopausal women. Evidence-based approaches to diagnosing and managing these symptoms are limited by inconsistencies in outcomes and measures used in clinical trials.

OBJECTIVE

The aim of the study was to systematically review all outcomes and measurement tools reported in randomized clinical trials of interventions for genitourinary symptoms associated with menopause.

EVIDENCE REVIEW

We searched PubMed, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) up to December 2018. Randomized controlled trials with a primary or secondary outcome of genitourinary symptoms associated with menopause, English language, and sample size of 20 or more women per study arm were included. Study characteristics, outcomes, and measurement methods were collected.

FINDINGS

The search yielded 3,478 articles of which 109 met inclusion criteria. Forty-eight different outcomes were reported with "atrophy" as the most common (56/109, 51%) followed by measures of sexual function (19/109, 17%). Almost all (108/109, 99%) trials included patient-reported measures, with 21 different measures and 39 symptom combinations. Clinician-reported scales of vulvovaginal appearance were used in 36 of 109 (33%) trials, with extensive variation in what was measured and reported. Cytological measures from the vaginal epithelium were the most commonly used objective tools (76/109, 70%).

CONCLUSIONS AND RELEVANCE

There is heterogeneity in reported outcomes and measures used in clinical trials of treatments for genitourinary symptoms at menopause and uncertainty as to which outcomes best reflect patient priorities and symptoms. The findings from this systematic review have informed an international survey of stakeholders to determine priorities for outcome selection and reporting. This survey will then inform the development of a Core Outcome Set for use in future clinical trials by the COMMA (Core OutcoMes in MenopAuse) consortium. : Video Summary:http://links.lww.com/MENO/A599.

The genitourinary syndrome of menopause

ABSTRACT

Genitourinary syndrome of menopause (GSM) refers to a collection of symptoms resulting from diminished hormonal, primarily estrogenic stimulation to the vulvovaginal or lower urinary tract and may affect up to 50% of postmenopausal women. Symptoms, which are typically progressive and unlikely to resolve spontaneously, may include, but are not limited to, vulvovaginal dryness, burning or irritation, dyspareunia, or urinary symptoms of urgency, dysuria or recurrent urinary tract infection. These symptoms are typically progressive and unlikely to resolve spontaneously. Diagnosis is clinical. Telemedicine may play a role in diagnosis, initiation of treatment, and follow-up of women with GSM. Effective treatments include moisturizers and lubricants, local hormonal therapy with estrogen or dehydroepiandrosterone, and oral selective estrogen receptor agonists. Laser or radiofrequency procedures, although currently utilized, are being studied to comprehensively understand their overall effectiveness and safety. Additionally, the influence and effect of the vaginal microbiome, as well as potential of treatment via its manipulation, is being studied. We performed a literature search of PubMed, Google Scholar, and Ovid with search terms of vulvovaginal atrophy and GSM and reviewed major US Society Guidelines to create this narrative review of this topic. The literature suggests that healthcare providers can make a significant impact of the health and quality of life of women by being proactive about discussing and providing interventions for GSM. A systematic approach with consideration of current guidelines and attention to developing protocols for interventions should be employed.

Clinical Efficacy of Hormonal and Nonhormonal Agents in the Treatment of Vulvovaginal Atrophy

Objectives

Symptomatic local treatment of vaginal atrophy (VA) in menopausal women includes hormonal and nonhormonal preparations. Some women may be reluctant to use vaginal estradiol preparations because of the concern for developing breast cancer and endometrial hyperplasia. Therefore, it is necessary to compare the therapeutic effectiveness of alternative vaginal drugs, such as promestriene, an estrogen agonist, and sodium hyaluronate (NaH), a nonhormonal, water-based agent.

Methods

Ninety-one postmenopausal women diagnosed with symptomatic VA were divided into three groups and treated for 12 weeks; 30 women with vaginal estradiol (VE), 30 women with promestriene, and 31 women with NaH. Composite scoring, vaginal maturation index (VMI), pH, frequency of sexual activity, serum hormone levels, and endometrial thickness were evaluated VA before and after treatment.

Results

In the comparison of VA examination findings composite scoring, VMI, and vaginal pH values, three different drugs were found to be effective in the treatment (P < 0.05). The VMI following VE treatment was significantly higher than that after NaH treatment (P = 0.031), whereas the promestriene group had a more positive change than the others in terms of increase in after treatment composite scoring and sexual activity frequency (P = 0.031, P = 0.020). There were no differences between the groups in terms of pre and after treatment serum E2 levels and endometrial thickness.

Conclusions

Based on these findings, we can conclude that the use of promestriene or NaH can prove to be as effective and well tolerated as vaginal estradiol in the symptomatic treatment of vaginal atrophy.

Effect of Vitamin D Supplement on Vulvovaginal Atrophy of the Menopause

The effects of oral vitamin D supplements on vaginal health in postmenopausal women with vulvovaginal atrophy (VVA) was evaluated. A double-blinded, randomized placebo-controlled trial was conducted for 12 weeks to investigate changes on vaginal maturation index (VMI), vaginal pH, and the visual analog scale (VAS) of VVA symptoms. The vitamin D group received oral ergocalciferol, at 40,000 IU per week, while the placebo group received an identical placebo capsule. Eighty postmenopausal women were enrolled. There were no significant differences in baseline characteristics between both groups. In an intention-to-treat analysis, VMI, vaginal pH, and VAS of VVA symptoms showed no significant differences between both groups at the six and 12 weeks. However, the mean difference of VMI in the vitamin D group between baseline and at six weeks showed significant improvement (5.5 + 16.27, p <0.05). Moreover, the mean vaginal pH and VAS of VVA patients in the vitamin D group were significantly improved at both six and 12 weeks compared to baseline. The oral vitamin D supplementation for 12 weeks potentially improves vaginal health outcomes in postmenopausal women with VVA symptoms, demonstrated by the improved mean VMI, vaginal pH, and VAS at six and 12 weeks between baseline, however, no significant differences were observed from the placebo treatment.

Effect of estradiol vaginal gel on vaginal atrophy in postmenopausal women: A randomized double-blind controlled trial

AIM

To evaluate the efficacy and safety of 25 μg of estradiol gel on postmenopausal vaginal tissue.

METHODS

This randomized double-blind controlled trial included postmenopausal women with vaginal atrophy who attended our menopause clinic during July 2017-January 2018. Women were randomly assigned to the estradiol gel group or control group (K-Y® Jelly). Treatment consisted of 2 mL of product applied intravaginally daily for 2 weeks, and two doses per week for the next 6 weeks. The most bothersome symptom (MBS), vaginal health index (VHI), vaginal pH, vaginal maturation index, vaginal maturation value (VMV), female sexual function index (FSFI), serum estradiol level and endometrial thickness were evaluated at baseline, 4 and 8 weeks.

RESULTS

Seventy-five of 80 women completed the trial. After 8 weeks of treatment, VMV, VHI, vaginal pH and FSFI improved significantly in the estradiol group, with no observed change in the control group. The MBS was decreased in both groups with no significant difference between groups. Serum estradiol level and endometrial thickness were not significantly different between groups at baseline or at week 8.

CONCLUSION

Estradiol vaginal gel demonstrated an ability to reverse vaginal atrophy with a high safety profile and low systemic absorption of estradiol.

The Effect of Lactobacillus acidophilus YT1 (MENOLACTO) on Improving Menopausal Symptoms: A Randomized, Double-Blinded, Placebo-Controlled Clinical Trial

This study evaluated the efficacy of Lactobacillus acidophilus YT1 (MENOLACTO) for alleviating menopausal symptoms. This study was a multi-center, randomized, double-blinded, placebo-controlled clinical trial involving female subjects (ages: 40-60 years) with menopausal symptoms and a Kupperman index (KMI) score ≥ 20. Subjects were administered 1 × 108 CFU/day MENOLACTO or placebo, with the primary endpoint being total KMI score, and the effect of secondary endpoints on alleviating menopausal symptoms according to individual categories of the modified KMI, as well as a quality of life questionnaire (MENQOL questionnaire). After 12 weeks, total KMI scores decreased significantly, demonstrating improved menopausal symptoms relative to placebo along with improved modified KMI scores. Additionally, quality of life, according to the MENQOL questionnaire, significantly improved in all four symptoms-physical, psychosocial, vasomotor, and sexual symptoms. Moreover, we observed no significant difference between the two groups or significant changes in blood follicle-stimulating hormone and estradiol levels or endometrial thickness. These results demonstrated that MENOLACTO alleviated menopausal symptoms without notable side effects and improved quality of life, suggesting its efficacy as an alternative supplement to alleviate menopausal symptoms in women ineligible for hormonal therapy.

Impact of microablative fractional radiofrequency on the vaginal health, microbiota, and cellularity of postmenopausal women

OBJECTIVES

We aimed to evaluate the effectiveness of microablative fractional radiofrequency (MAFRF) in the non-hormonal treatment of genitourinary syndrome of menopause.

METHODS

We examined the cases of 55 postmenopausal women before and after treatment with regard to their vaginal health index (VHI), vaginal microbiota, vaginal pH, and cell maturation. Three applications of MAFRF were performed in the vagina/vaginal introitus. During the treatment, six vaginal smears were obtained and stained with the Papanicolaou stain for determining the degree of cell maturation and with Gram stain for classification of vaginal flora, as per the criteria of Spiegel and Amsel. For vaginal pH determination, pH indicator strips were applied against the vaginal wall. Statistical analysis was performed using SPSS for Windows (version 17.0). Data were reported as mean±standard deviation. The differences were analyzed using the statistical method of generalized estimation equations with autoregressive correlation structure "1" and robust standard errors.

RESULTS

The mean age was 59.8±4.2 years, and the mean time of menopause was 15.4±4.5 years. After treatment, there was an increase in the percentage of Lactobacillus spp. (p<0.001). Consequently, there was a progressive decrease in vaginal pH during the treatment (p<0.001). Regarding cell maturation, there was a decrease in the percentage of parabasal cells (p=0.001) and an increase in the rate of superficial cells (p<0.001). Additionally, there was an improvement in the VHI index. The mean VHI values before and after treatment were 13.2±5.6 and 22.5±3.7, respectively (p<0.001).

CONCLUSION

MAFRF treatment is well tolerated and leads to improvement in the vaginal microenvironment.

Treatment of genitourinary syndrome of menopause: the potential effects of intravaginal ultralow-concentration oestriol and intravaginal dehydroepiandrosterone on quality of life and sexual function

The climacteric is considered a natural phase in a woman's aging process and is defined as the period starting from the decline in ovarian activity until after the end of ovarian function. Genitourinary syndrome of menopause (GSM) is commonly observed in menopausal women and is characterised by a collection of symptoms resulting from changes to the internal and external genitalia as well as the lower urinary tract. Several studies have demonstrated the close association between sexual dysfunction and symptoms related to GSM. Many medications, at different doses, have been studied over the years for the treatment of the symptoms of GSM. More specifically, ultralow-dose intravaginal oestriol and intravaginal dehydroepiandrosterone (DHEA) are reported to improve symptoms, signs, and quality of life of women with GSM, and they are safe owing to their specific local effect. While the dosage and the administration of intravaginal DHEA are well defined, the literature on intravaginal oestriol is less uniform: different doses and times of administration are proposed with different possible combinations with other non-pharmacological therapies, although a more standardised treatment may be necessary. The aim of this review is to summarise the available data about the effects of ultralow-concentration oestriol and intravaginal DHEA on the menopause-related symptoms, quality of life, and sexual function of women affected by GSM.

Therapeutic Approaches to Atrophic Vaginitis in Postmenopausal Women: A Systematic Review with a Network Meta-analysis of Randomized Controlled Trials

Objectives

Atrophic vaginitis (AV), which is common in postmenopausal women, is characterized by vaginal dryness, dyspareunia, and discomfort. There are a variety of therapeutic agents for the treatment of AV, besides hormone replacement therapy. We performed this systematic review to compare the effectiveness of various therapies for symptom improvement in AV patients.

Methods

We searched the Cochrane Library, EMBASE, MEDLINE, and other literature (Google Scholar, Web of Science, and hand search) for studies published between January 2010 and March 2015. AV was evaluated by the following outcomes: vaginal pH, dyspareunia, vaginal dryness, or cytological change (endometrial thickness, percentages of superficial cells and parabasal cells). They measured treatment efficacy with various outcomes pertaining to AV symptoms.

Results

Meta-analysis suggested that ospemifene was effective against dyspareunia, vaginal dryness, endometrial thickness, and percentage changes in superficial and parabasal cells. Vaginal pH was most affected by soy isoflavone vaginal gel. Ospemifene was effective for AV symptoms.

Conclusions

This systematic review compared the effects of several therapeutic agents on symptoms of AV through a network meta-analysis. This study provides objective evidence for clinical treatment and efficacy management in AV.

Treatment of vaginal atrophy with estriol and lactobacilli combination: a clinical review

In recent years, a vast quantity of clinical data has been accumulated on the pathophysiology of symptomatic vulvovaginal atrophy (VVA)/genitourinary syndrome of menopause (GSM) in peri- and postmenopausal women and on the treatment options for these conditions. Guidelines from several societies have recently been updated in favor of VVA/GSM vaginal therapy with the lowest possible doses of estrogens. The combination of a vaginal ultra-low dose of 0.03 mg of estriol (E3) and lyophilized, viable Lactobacillus acidophilus KS400 (0.03 mg-E3/L) is a unique product with a dual mechanism of action supporting not only the proliferation and maturation of the vaginal epithelium, but also restoration of the lactobacillary microflora. It has been demonstrated efficiently to establish and maintain a healthy vaginal ecosystem. Use of this combination considerably improves the clinical signs and symptoms as well as the quality of life of menopausal women suffering from vaginal atrophy. This combination therapy is well tolerated with a low overall incidence of side-effects and negligible estriol absorption. Based on recent scientific evidence and current treatment guidelines, the 0.03 mg-E3/L combination could be considered one of the options for the treatment of symptomatic vaginal atrophy in aging menopausal women.

Aerobic vaginitis: no longer a stranger

Aerobic vaginitis (AV) is the name given in 2002 to a vaginal infectious entity which was not recognized as such before. It is characterized by abnormal (dysbiotic) vaginal microflora containing aerobic, enteric bacteria, variable levels of vaginal inflammation and deficient epithelial maturation. Although AV and bacterial vaginosis (BV) share some characteristics, such as a diminished number or absence of lactobacilli, increased discharge (fishy smelling in BV, while in severe forms of AV, a foul, rather rotten smell may be present) and increased pH (often more pronounced in AV), there are also striking differences between the two. There is no inflammation in women with BV, whereas the vagina of women with AV often appears red and edematous, and may even display small erosions or ulcerations. The color of the discharge in BV is usually whitish or gray and of a watery consistency, whereas in AV it is yellow to green and rather thick and mucoid. Women with BV do not have dyspareunia, while some women with severe AV do. Finally, the microscopic appearance differs in various aspects, such as the presence of leucocytes and parabasal or immature epithelial cells in AV and the absence of the granular aspect of the microflora, typical of BV. Despite all these differences, the distinction between AV and BV was not recognized in many former studies, leading to incomplete and imprecise diagnostic workouts and erroneous management of patients in both clinical and research settings. The prevalence of AV ranges between 7 and 12%, and is therefore less prevalent than BV. Although still largely undiagnosed, many researchers and clinicians increasingly take it into account as a cause of symptomatic vaginitis. AV can co-occur with other entities, such as BV and candidiasis. It can be associated with dyspareunia, sexually transmitted infections (such as human papilloma virus, human immunodeficiency virus, Trichomonas vaginalis and Chlamydia trachomatis), chorioamnionitis, fetal infection, preterm birth and cervical dysplasia. Many other possible pathological associations are currently under investigation. The diagnosis of AV is made using wet mount microscopy, ideally using phase contrast. An AV score is calculated, according to: lactobacillary grade, presence of inflammation, proportion of toxic leucocytes, characteristics of the microflora and presence of immature epithelial cells. To circumvent the hurdle of microscopic investigation, some groups have begun to develop nucleic-acid-based and enzymatic diagnostic tests, but the detailed information obtained with phase contrast microscopy is irreplaceable. The best treatment is not yet fully determined, but it must be tailored according to the microscopic findings and the patient's needs. There is a role for local estrogen therapy, corticosteroids, antimicrobials and probiotics. Further research will reveal more precise data on diagnosis, pathogenesis, management and prevention.

A Dermatologist’s Approach to Genitourinary Syndrome of Menopause

Background:

Genitourinary syndrome of menopause (GSM) is a debilitating condition caused by hypoestrogenism that presents with vaginal dryness and dyspareunia as well as other genital, sexual, and urinary symptoms. Previously known as atrophic vaginitis, the term GSM is now used.

Objective:

To help familiarise dermatologists with diagnosing and managing GSM.

Methods:

In total, 218 articles were identified and reviewed by 2 independent authors using PubMed. Articles included were from December 2005 to December 2015. Sixty-seven articles met our inclusion criteria.

Results:

GSM is a clinical diagnosis, requiring the presence of symptoms that should be bothersome and not accounted for by another condition. A pH test may help with diagnosis as vaginal pH will be increased from acidic to neutral. The Papanicolaou test is not recommended because of poor clinical correlation. First-line treatment is low-dose local vaginal estrogen therapy, which has proven efficacy and safety. Serum estrogen levels are not significantly affected with the exception of creams containing high-dose conjugated equine estrogens. Other options have yet to be approved for use in Canada but show promise.

Conclusion:

GSM is a debilitating and common condition that suffers from barriers to diagnosis and treatment. Current treatments are well tolerated, rewarding, and effective with rapid onset.

Bioidentical menopausal hormone therapy: registered hormones (non-oral estradiol ± progesterone) are optimal

The many advantages of registered bioidentical sex hormones over registered, conventional, non-bioidentical menopausal hormone therapy (MHT) are considered. The transdermal route of estrogen administration avoids excess venous thromboembolic and ischemic stroke events. There is some indication that conjugated equine estrogens are more thrombogenic and most likely induce some hypertensive responses; estradiol might also be superior to conjugated equine estrogens (CEE) in terms of global cardiovascular health. The most valid evidence presently suggests that CEE-only treatment does not increase the risk of breast cancer and even may reduce it. But its combination with a synthetic progestogen (mainly medroxyprogesterone acetate) is a critical issue since it seems to be primarily associated with an increased incidence of breast cancer, however similar to or lower than that associated with some common lifestyle factors. Though not yet proven in a randomized, controlled trial, MHT continuously combining oral micronized progesterone with transdermal estradiol can presently be considered as the optimal MHT. It is not only safer than custom-compounded bioidentical hormones but also than oral conventional MHT and has the best breast profile; registered products for such optimal MHT are available around the world and must be preferred.

Microablative fractional CO2-laser therapy and the genitourinary syndrome of menopause: An observational study

OBJECTIVES

This study aimed to assess the effect of the Microablative Fractional CO₂ Laser (CO₂-laser) therapy on vaginal pathophysiology and the symptoms of the Genitourinary Syndrome of Menopause (GSM).

METHODS

Postmenopausal women with moderate to severe symptoms of GSM underwent three sessions of CO₂-laser therapy at monthly intervals. Participants were evaluated at baseline and 4 weeks after the last treatment.

MAIN OUTCOME MEASURES

The primary outcomes were Vaginal Maturation Value (VMV) and Vaginal Health Index Score (VHIS). Secondary outcomes included symptoms of GSM, Female Sexual Function Index (FSFI), International Consultation on Incontinence Questionnaire of Female Urinary Tract Symptoms (ICIQ-FLUTS) and Urinary Incontinence Short Form (ICIQ-UI SF), Urogenital Distress Inventory (UDI-6) and King's Health Questionnaire (KHQ).

RESULTS

Fifty-three postmenopausal women completed this study. VMV, VHIS and FSFI increased significantly. Dyspareunia, dryness, burning, itching, dysuria, frequency, urgency, urgency incontinence, stress incontinence and scores on the ICIQ-FLUTS, ICIQ-UI SF, UDI-6 and KHQ decreased significantly. Factors predicting for which women the CO₂-laser therapy was more effective were not identified.

CONCLUSION

This study suggests that intravaginal CO₂-laser therapy for postmenopausal women with clinical signs and symptoms of GSM may be effective in improving both vaginal pathophysiology and reported symptoms.

Local oestrogen for vaginal atrophy in postmenopausal women

BACKGROUND

Vaginal atrophy is a frequent complaint of postmenopausal women; symptoms include vaginal dryness, itching, discomfort and painful intercourse. Systemic treatment for these symptoms in the form of oral hormone replacement therapy is not always necessary. An alternative choice is oestrogenic preparations administered vaginally (in the form of creams, pessaries, tablets and the oestradiol-releasing ring). This is an update of a Chochrane systematic review; the original version was first published in October 2006.

OBJECTIVES

The objective of this review was to compare the efficacy and safety of intra-vaginal oestrogenic preparations in relieving the symptoms of vaginal atrophy in postmenopausal women.

SEARCH METHODS

We searched the following databases and trials registers to April 2016: Cochrane Gynaecology and Fertility Group Register of trials, The Cochrane Central Register of Controlled Trials (CENTRAL; 2016 issue 4), MEDLINE, Embase, PsycINFO, DARE, the Web of Knowledge, OpenGrey, LILACS, PubMed and reference lists of articles. We also contacted experts and researchers in the field.

SELECTION CRITERIA

The inclusion criteria were randomised comparisons of oestrogenic preparations administered intravaginally in postmenopausal women for at least 12 weeks for the treatment of symptoms resulting from vaginal atrophy or vaginitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and risk of bias and extracted the data. The primary review outcomes were improvement in symptoms (participant-assessed), and the adverse event endometrial thickness. Secondary outcomes were improvement in symptoms (clinician-assessed), other adverse events (breast disorders e.g. breast pain, enlargement or engorgement, total adverse events, excluding breast disorders) and adherence to treatment. We combined data to calculate pooled risk ratios (RRs) (dichotomous outcomes) and mean differences (MDs) (continuous outcomes) and 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I(2) statistic. We assessed the overall quality of the evidence for the main comparisons using GRADE methods.

MAIN RESULTS

We included 30 RCTs (6235 women) comparing different intra-vaginal oestrogenic preparations with each other and with placebo. The evidence was low to moderate quality; limitations were poor reporting of study methods and serious imprecision (effect estimates with wide confidence intervals)1. Oestrogen ring versus other regimensOther regimens included oestrogen cream, oestrogen tablets and placebo. There was no evidence of a difference in improvement in symptoms (participant assessment) either between oestrogen ring and oestrogen cream (odds ratio (OR) 1.33, 95% CI 0.80 to 2.19, two RCTs, n = 341, I(2) = 0%, low-quality evidence) or between oestrogen ring and oestrogen tablets (OR 0.78, 95% CI 0.53 to 1.15, three RCTs, n = 567, I(2) = 0%, low-quality evidence). However, a higher proportion of women reported improvement in symptoms following treatment with oestrogen ring compared with placebo (OR 12.67, 95% CI 3.23 to 49.66, one RCT, n = 67). With respect to endometrial thickness, a higher proportion of women who received oestrogen cream showed evidence of increase in endometrial thickness compared to those who were treated with oestrogen ring (OR 0.36, 95% CI 0.14 to 0.94, two RCTs, n = 273; I(2) = 0%, low-quality evidence). This may have been due to the higher doses of cream used. 2. Oestrogen tablets versus other regimensOther regimens in this comparison included oestrogen cream, and placebo. There was no evidence of a difference in the proportions of women who reported improvement in symptoms between oestrogen tablets and oestrogen cream (OR 1.06, 95% CI 0.55 to 2.01, two RCTs, n = 208, I(2) = 0% low-quality evidence). A higher proportion of women who were treated with oestrogen tablets reported improvement in symptoms compared to those who received placebo using a fixed-effect model (OR 12.47, 95% CI 9.81 to 15.84, two RCTs, n = 1638, I(2) = 83%, low-quality evidence); however, using a random-effect model did not demonstrate any evidence of a difference in the proportions of women who reported improvement between the two treatment groups (OR 5.80, 95% CI 0.88 to 38.29). There was no evidence of a difference in the proportions of women with increase in endometrial thickness between oestrogen tablets and oestrogen cream (OR 0.31, 95% CI 0.06 to 1.60, two RCTs, n = 151, I(2) = 0%, low-quality evidence).3. Oestrogen cream versus other regimensOther regimens identified in this comparison included isoflavone gel and placebo. There was no evidence of a difference in the proportions of women with improvement in symptoms between oestrogen cream and isoflavone gel (OR 2.08, 95% CI 0.08 to 53.76, one RCT, n = 50, low-quality evidence). However, there was evidence of a difference in the proportions of women with improvement in symptoms between oestrogen cream and placebo with more women who received oestrogen cream reporting improvement in symptoms compared to those who were treated with placebo (OR 4.10, 95% CI 1.88 to 8.93, two RCTs, n = 198, I(2) = 50%, low-quality evidence). None of the included studies in this comparison reported data on endometrial thickness.

AUTHORS' CONCLUSIONS

There was no evidence of a difference in efficacy between the various intravaginal oestrogenic preparations when compared with each other. However, there was low-quality evidence that intra-vaginal oestrogenic preparations improve the symptoms of vaginal atrophy in postmenopausal women when compared to placebo. There was low-quality evidence that oestrogen cream may be associated with an increase in endometrial thickness compared to oestrogen ring; this may have been due to the higher doses of cream used. However there was no evidence of a difference in the overall body of evidence in adverse events between the various oestrogenic preparations compared with each other or with placebo.

The effect of microablative fractional CO2 laser on vaginal flora of postmenopausal women

OBJECTIVES

To assess the effect of microablative fractional CO2 laser (MFCO2-Laser) therapy on the vaginal microenvironment of postmenopausal women.

METHODS

Three laser therapies at monthly intervals were applied in postmenopausal women with moderate to severe symptoms of genitourinary syndrome of menopause, pH of vaginal fluid >4.5 and superficial epithelial cells on vaginal smear <5%. Vaginal fluid pH values, fresh wet mount microscopy, Gram stain and aerobic and anaerobic cultures were evaluated at baseline and 1 month after each subsequent therapy. Nugent score and Hay-Ison criteria were used to evaluate vaginal flora.

RESULTS

Fifty-three women (mean age 57.2 ± 5.4 years) participated and completed this study. MFCO2-Laser therapy increased Lactobacillus (p < 0.001) and normal flora (p < 0.001) after the completion of the therapeutic protocol, which decreased vaginal pH from a mean of 5.5 ± 0.8 (initial value) to 4.7 ± 0.5 (p < 0.001). The prevalence of Lactobacillus changed from 30% initially to 79% after the last treatment. Clinical signs and symptoms of bacterial vaginosis, aerobic vaginitis or candidiasis did not appear in any participant.

CONCLUSION

MFCO2-Laser therapy is a promising treatment for improving the vaginal health of postmenopausal women by helping repopulate the vagina with normally existing Lactobacillus species and reconstituting the normal flora to premenopausal status.

Cervicovaginal Microbiomes-Threats and Possibilities

The microbiome of the vagina has universal traits that override race, diet, lifestyle, and socioeconomic status. While five community state types have been proposed, the actual number is likely closer to ten. Nevertheless, while lactobacilli dominate in health for most women, a highly diverse community or single pathogens are associated with morbidity. The fact that four or five Lactobacillus species are dominant in healthy women worldwide, raises questions of why they evolved in this niche, what they are doing, and how their apparent protective properties can be harnessed? This opinion article explores this universality, elements of lactobacilli that may imprint women's health and that of their offspring, and proposes key areas for future study.

Local Oestrogen for Pelvic Floor Disorders: A Systematic Review

OBJECTIVE

The decline in available oestrogen after menopause is a possible etiological factor in pelvic floor disorders like vaginal atrophy (VA), urinary incontinence (UI), overactive bladder (OAB) and pelvic organ prolapse (POP). This systematic review will examine the evidence for local oestrogen therapy in the treatment of these pelvic floor disorders.

EVIDENCE ACQUISITION

We performed a systematic search in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the non-MEDLINE subset of PubMed from inception to May 2014. We searched for local oestrogens and VA (I), UI/OAB (II) and POP (III). Part I was combined with broad methodological filters for randomized controlled trials (RCTs) and secondary evidence. For part I and II two reviewers independently selected RCTs evaluating the effect of topical oestrogens on symptoms and signs of VA and UI/OAB. In part III all studies of topical oestrogen therapy in the treatment of POP were selected. Data extraction and the assessment of risk of bias using the Cochrane Risk of Bias Tool was undertaken independently by two reviewers.

EVIDENCE SYNTHESIS

The included studies varied in ways of topical application, types of oestrogen, dosage and treatment durations. Objective and subjective outcomes were assessed by a variety of measures. Overall, subjective and urodynamic outcomes, vaginal maturation and vaginal pH changed in favor of vaginal oestrogens compared to placebo. No obvious differences between different application methods were revealed. Low doses already seemed to have a beneficial effect. Studies evaluating the effect of topical oestrogen in women with POP are scarce and mainly assessed symptoms and signs associated with VA instead of POP symptoms.

CONCLUSION

Topical oestrogen administration is effective for the treatment of VA and seems to decrease complaints of OAB and UI. The potential for local oestrogens in the prevention as well as treatment of POP needs further research.

Profiles and technological requirements of urogenital probiotics

Probiotics, defined as live microorganisms that, when administered in adequate amounts, confer a health benefit on the host, are considered a valid and novel alternative for the prevention and treatment of female urogenital tract infections. Lactobacilli, the predominant microorganisms of the healthy human vaginal microbiome, can be included as active pharmaceutical ingredients in probiotics products. Several requirements must be considered or criteria fulfilled during the development of a probiotic product or formula for the female urogenital tract. This review deals with the main selection criteria for urogenital probiotic microorganisms: host specificity, potential beneficial properties, functional specifications, technological characteristics and clinical trials used to test their effect on certain physiological and pathological conditions. Further studies are required to complement the current knowledge and support the clinical applications of probiotics in the urogenital tract. This therapy will allow the restoration of the ecological equilibrium of the urogenital tract microbiome as well as the recovery of the sexual and reproductive health of women.

Effect of ultra-low-dose estriol and lactobacilli vaginal tablets (Gynoflor®) on inflammatory and infectious markers of the vaginal ecosystem in postmenopausal women with breast cancer on aromatase inhibitors

This study was a detailed microscopic analysis of the changes of vaginal microflora characteristics after application of 0.03 mg estriol-lactobacilli combination on the vaginal ecosystem in postmenopausal breast cancer (BC) survivors on aromatase inhibitors (AI) with severe atrophic vaginitis. A total of 16 BC women on AI applied daily one vaginal tablet of Gynoflor® for 28 days followed by a maintenance therapy of three tablets weekly for 8 weeks. During four follow up visits a smear from the upper lateral vaginal wall was analysed by phase contrast microscopy at 400 times magnification in order to classify the lactobacillary grades(LBG), bacterial vaginosis (BV), aerobic vaginitis (AV), vulvovaginal candidosis (VVC), proportional number of leukocytes and evidence of parabasal cells and epitheliolysis. LBG improved from 81 % LBG-III at entry to 88 % LBG-I&IIa after 2 weeks of initial therapy, which further improved upon follow up (p < 0.001). Whereas BV was a rare event, AV was frequent and substantially improved during treatment (p < 0.01). While at entry most patients had moderate or severe AV, after maintenance therapy no patient except one had AV. The number of leukocytes dropped dramatically from a score of 1.78 ± 0.70 to 1.06 ± 0.25 which was consistent till the end of the study (p < 0.01). Parabasal cells dropped from a score of 3.4 ± 0.64 at entry to 1.3 ± 0.60 at the final visit (p_trend < 0.01). Starting from a low rate of Candida colonisation of 2/14 (14 %), a sudden rise to 7/16 (44 %) occurred after 2 weeks, to return back to base levels at susequent visits. The vaginal use of ultra-low dose estriol and lactobacilli results in rapid and enduring improvement of all markers of the vaginal microflora and epithelial vaginal cell quality in women with breast cancer on AI with dyspareunia. Candida may develop soon after its use, but rapidly disappears again upon their prolonged use. Due to its excellent safety profiles and clinical efficacy we recommend this product as first choice in women on AI with severe dyspareunia.

Selecting anti-microbial treatment of aerobic vaginitis

Aerobic vaginitis (AV) is a vaginal infectious condition which is often confused with bacterial vaginosis (BV) or with the intermediate microflora as diagnosed by Nugent's method to detect BV on Gram-stained specimens. However, although both conditions reflect a state of lactobacillary disruption in the vagina, leading to an increase in pH, BV and AV differ profoundly. While BV is a noninflammatory condition composed of a multiplex array of different anaerobic bacteria in high quantities, AV is rather sparely populated by one or two enteric commensal flora bacteria, like Streptococcus agalactiae, Staphylocuccus aureus, or Escherichia coli. AV is typically marked by either an increased inflammatory response or by prominent signs of epithelial atrophy or both. The latter condition, if severe, is also called desquamative inflammatory vaginitis. As AV is per exclusionem diagnosed by wet mount microscopy, it is a mistake to treat just vaginal culture results. Vaginal cultures only serve as follow-up data in clinical research projects and are at most used in clinical practice to confirm the diagnosis or exclude Candida infection. AV requires treatment based on microscopy findings and a combined local treatment with any of the following which may yield the best results: antibiotic (infectious component), steroids (inflammatory component), and/or estrogen (atrophy component). In cases with Candida present on microscopy or culture, antifungals must be tried first in order to see if other treatment is still needed. Vaginal rinsing with povidone iodine can provide rapid relief of symptoms but does not provide long-term reduction of bacterial loads. Local antibiotics most suitable are preferably non-absorbed and broad spectrum, especially those covering enteric gram-positive and gram-negative aerobes, like kanamycin. To achieve rapid and short-term improvement of severe symptoms, oral therapy with amoxyclav or moxifloxacin can be used, especially in deep dermal vulvitis and colpitis infections with group B streptococci or (methicillin resistant) Staphylococcus aureus. Since the latter colonizations are frequent, but seldom inflammatory infections, we in general discourage the use of oral antibiotics in women with AV. In cases with a severe atrophy component (more than 10 % of epithelial cells are of the parabasal type), local estrogens can be used; and in postmenopausal or breast cancer patients with a contraindication for estrogens, even a combination of probiotics with an ultra-low dose of local estriol may be considered.

Vaginal estriol-lactobacilli combination and quality of life in endocrine-treated breast cancer

OBJECTIVE

We investigated the effect of a combination of vaginal ultra-low-dose estriol with lactobacilli on the sexual functioning domain of quality of life during the treatment of breast cancer survivors on an aromatase inhibitor with vaginal atrophy.

SUBJECTS AND METHODS

This was an open-label, bicentric, exploratory, clinical study in 16 postmenopausal breast cancer survivors on aromatase inhibitors suffering from vaginal atrophy-induced sexual disorders. Atrophy symptoms were assessed by scoring with an 11-point estimation scale (0 = not at all, 10 = worst imaginable feeling). Sexuality parameters of quality of life and medication adherence were recorded in a patient's diary and in the Female Somatic Sexual Experience Instrument (FSSEI) questionnaire. Patients underwent an initial treatment for 4 weeks (one vaginal tablet of Gynoflor(®) containing 0.03 mg estriol daily), followed by maintenance therapy (three vaginal Gynoflor(®) tablets weekly) for 8 weeks.

RESULTS

Vaginal dryness continuously improved from a median score of 8 at entry to a score of 4 at the end of initial therapy, and a median score of 2 at the end of maintenance therapy. Normal sexual activity before breast cancer diagnosis was reported by 14 women (88%). At study entry, only three women (19%) were sexually active. At the end of the Gynoflor(®) regimen, ten women (63%) reported sexual activity, of which seven (44%) reported sexual intercourse. The FSSEI demonstrated a non-significant trend of improvement of parameters related to sexuality.

CONCLUSIONS

Local vaginal therapy with Gynoflor(®) in breast cancer survivors on aromatase inhibitors reporting atrophic vaginitis could be considered as a useful treatment for the quality of sexual life.

Ultra-low-dose estriol and Lactobacillus acidophilus vaginal tablets (Gynoflor(®)) for vaginal atrophy in postmenopausal breast cancer patients on aromatase inhibitors: pharmacokinetic, safety, and efficacy phase I clinical study

Phase I pharmacokinetic (PK) study assessed circulating estrogens in breast cancer (BC) patients on a non-steroidal aromatase inhibitor (NSAI) with vaginal atrophy using vaginal ultra-low-dose 0.03 mg estriol (E3) and Lactobacillus combination vaginal tablets (Gynoflor^®). 16 women on NSAI with severe vaginal atrophy applied a daily vaginal tablet of Gynoflor^® for 28 days followed by a maintenance therapy of 3 tablets weekly for 8 weeks. Primary outcomes were serum concentrations and PK of E3, estradiol (E2), and estrone (E1) using highly sensitive gas chromatography–mass spectrometry. Secondary outcomes were clinical measures for efficacy and side effects; microscopic changes in vaginal epithelium and microflora; and changes in serum FSH, LH, and sex hormone-binding globulin. Compared with baseline, serum E1 and E2 did not increase in any of the women at any time following vaginal application. Serum E3 transiently increased after the first application in 15 of 16 women, with a maximum of 168 pg/ml 2–3 h post-insertion. After 4 weeks, serum E3 was slightly increased in 8 women with a maximum of 44 pg/ml. The vaginal atrophy resolved or improved in all women. The product was well tolerated, and discontinuation of therapy was not observed. The low-dose 0.03 mg E3 and Lactobacillus acidophilus vaginal tablets application in postmenopausal BC patients during AI treatment suffering from vaginal atrophy lead to small and transient increases in serum E3, but not E1 or E2, and therefore can be considered as safe and efficacious for treatment of atrophic vaginitis in BC patients taking NSAIs.

Reviewing the options for local estrogen treatment of vaginal atrophy

BACKGROUND

Vaginal atrophy is a chronic condition with symptoms that include vaginal dryness, pain during sex, itching, irritation, burning, and discharge, as well as various urinary problems. Up to 45% of postmenopausal women may be affected, but it often remains underreported and undertreated. This article aims to review the current recommendations for treatment of vaginal atrophy, and current data on the effectiveness and safety of local vaginal estrogen therapies.

METHODS

Literature regarding vaginal atrophy (2007-2012) was retrieved from PubMed and summarized, with emphasis on data related to the treatment of vaginal atrophy with local vaginal estrogen therapy.

RESULTS

Published data support the effectiveness and endometrial safety of low-dose local estrogen therapies. These results further support the general recommendation by the North American Menopause Society that a progestogen is not needed for endometrial protection in patients using low-dose local vaginal estrogen. Benefits of long-term therapy for vaginal atrophy include sustained relief of symptoms as well as physiological improvements (eg, decreased vaginal pH and increased blood flow, epithelial thickness, secretions).

CONCLUSION

Currently available local vaginal estrogen therapies are well tolerated and effective in relieving symptoms of vaginal atrophy. Recent data support the endometrial safety of low-dose regimens for up to 1 year.