CLINICAL QUESTION

What treatments are effective in women with vulvovaginal, urinary, or sexual symptoms due to menopause?

BOTTOM LINE

Based on low-certainty evidence, vaginal estrogen and vaginal moisturizer may help dyspareunia and vaginal dryness associated with menopause. Ospemifene (Osphena), an oral nonhormonal medication that affects estrogen receptors, may be a useful option for patients who do not achieve satisfactory results with topical treatments. The included studies were only a few months' duration. (Level of Evidence = 1a)

SYNOPSIS

The researchers searched three databases (but not Cochrane CENTRAL) to find 46 unique, English-language randomized controlled trials that evaluated vaginal estrogen, hormone therapies without estrogen, and vaginal moisturizers for the treatment of genitourinary syndrome of menopause. Most studies were sponsored by manufacturers. The study populations, entry criteria, and outcomes were too varied to allow for meta-analysis or comparison of relative benefit. Across symptoms, the certainty of evidence was graded as low for all treatments, meaning the researchers were not confident in the quality of the research. Vaginal estrogen (cream or vaginal ring) improves vaginal dryness, the most bothersome symptom identified by patients, and dyspareunia without affecting other symptoms, and patients report higher satisfaction with vaginal estrogen than with placebo. Vaginal moisturizers improve dryness. Ospemifene improves vaginal dryness and dyspareunia and has high-certainty evidence of high treatment satisfaction in three large studies. Few studies have evaluated the effect of vaginal estrogen on dysuria; those that did found no benefit.