Optimizing vaginal atrophy treatment

Vulvovaginal atrophy (VVA) is considered to be a consequence of estrogen-deficient conditions and disorders of the vaginal microbiocenosis. The disease is most often found in periand postmenopausal age. A large number of estrogen receptors are found in the mucous membrane of the vagina, vulva, urethra, bladder, muscles and ligaments of the pelvis; that is why against the background of hypoestrogenia, the tissues become atrophic, their extensibility and strength decrease. Symptoms of VVA are common, but underestimated by women and gynecologists worldwide due to the psychosocial determinant – the perception of VA symptoms as manifestations of inevitable aging process, not worthy of treatment. Most patients do not expect any medical help from a gynecologist, perceiving vaginal discomfort, such as vaginal dryness, dyspareunia, and vaginal itching as age-related and natural manifestations of aging. That is why during the routine examination of perimenopausal and postmenopausal patients, gynecologists should regularly inquire about the symptoms of genitourinary menopausal syndrome. Timely diagnosis and treatment can halt the progression of GUMS. Therapy with local estrogen forms is the gold standard for the treatment of GUMS; particularly, intravaginal estriol has no age restrictions, unlike menopausal hormone therapy, and can be prescribed to women over 60 years of age. Local estrogens relieve itching, and vaginal dryness, normalize vaginal microflora and low vaginal pH, helping to reduce the incidence of recurrent urogenital nonspecific infections in postmenopausal women. The article will present modern international and domestic guidelines for timely detection of genitourinary menopausal syndrome and its relevant safe treatment with topical use of ultra-low doses of estriol and acidophilic lactobacilli.

1. Сухих ГТ, Серов ВН (ред.). Гинекология по Уильямсу. М.: ГЭОТАР-Медиа; 2023. 1280 с.

2. Савельева ГМ, Сухих ГТ, Манухина ИБ (ред.). Гинекология. Национальное руководство: краткое издание. М.: ГЭОТАР-Медиа; 2017. 704 с.

3. Радзинский ВЕ (ред.). Урогенитальные расстройства: актуальные подходы к диагностике и лечению: информационный бюллетень. М.: StatusPraesens; 2016. 22 с.

4. Brady PH, Gin GT, Rosenblum E, Wilkinson LD. Female Pelvic Conditions: Genitourinary Syndrome of Menopause. FP Essent. 2022;515:32–42. Available at: https://pubmed.ncbi.nlm.nih.gov/35420405.

5. Hirschberg AL, Bitzer J, Cano A, Ceausu I, Chedraui P, Durmusoglu F et al. Topical estrogens and non-hormonal preparations for postmenopausal vulvovaginal atrophy: An EMAS clinical guide. Maturitas. 2021;148:55–61. https://doi.org/10.1016/j.maturitas.2021.04.005.

6. Newson L, Kirby M, Stillwell S, Hackett G, Ball S, Lewis R. Position Statement for Management of Genitourinary Syndrome of the Menopause (GSM): guideline. BSSM; 2024. 14 p. Available at: https://bssm.org.uk/wpcontent/uploads/2024/03/BSSM-Position-statement-for-management-ofgenitourinary-syndrome-of-the-menopause-GSM.pdf.

7. Andreeva EN, Sheremetyeva EV. The role of estriol in the treatment of atrophy of the mucous membrane of the lower genitourinary tract in postmenopausal women. Problemy Endokrinologii. 2022;68(6):157–163. (In Russ.) https://doi.org/10.14341/probl13198.

8. Donders GGG, Donders FHWV. New developments in the management of vulvovaginal atrophy: a comprehensive overview. Expert Opin Pharmacother. 2023;24(5):599–616. https://doi.org/10.1080/14656566.2023.2194017.

9. Brady PH, Gin GT, Rosenblum E, Wilkinson LD. Female Pelvic Conditions: Genitourinary Syndrome of Menopause. FP Essent. 2022;515:32–42. Available at: https://pubmed.ncbi.nlm.nih.gov/35420405.

10. Chen YY, Su TH, Lau HH. Estrogen for the prevention of recurrent urinary tract infections in postmenopausal women: a meta-analysis of randomized controlled trials. Int Urogynecol J. 2021;32(1):17–25. https://doi.org/10.1007/s00192-020-04397-z.

11. Park MG, Cho S, Oh MM. Menopausal Changes in the Microbiome – A Review Focused on the Genitourinary Microbiome. Diagnostics. 2023;13(6):1193. https://doi.org/10.3390/diagnostics13061193.

12. Радзинский ВЕ, Савичева АМ, Бебнева ТН, Гомберг МА, Маклецова СА, Свидзинский АВ и др. Синдром патологических выделений из половых путей женщины. Клинический протокол. М.: StatusPraesens; 2024. 112 c. Режим доступа: https://praesens.ru/broshyury/mars_svv.

13. Адамян ЛВ, Андреева ЕН, Аполихина ИА, Артымук НВ, Ашрафян ЛА, Балан ВЕ и др. Менопауза и климактерическое состояние у женщины: клинические рекомендации. 2024. 93 c. Режим доступа: https://pharmvestnik.ru/apps/fv/assets/storage/content/news/866/86685/menopauza_i_klimaktericheskoe_sostoyanie_u_zhenshchinyversiya_2024_goda.pdf.

14. Palacios S. Managing urogenital atrophy. Maturitas. 2009;63(4):315–318. https://doi.org/10.1016/j.maturitas.2009.04.009.

15. Vieira-Baptista P, Stockdale CK, Sobel J (eds.). International Society for the Study of Vulvovaginal Disease. Recommendations for the Diagnosis and Treatment of Vaginitis. Lisbon: Admedic; 2023. 195 p. Available at: https://www.issvd.org/application/files/4916/7897/2719/ISSVD_recommendations_for_the_diagnosis_and_treatment_of_vaginitis.pdf.

16. Costello EK, DiGiulio DB, Robaczewska A, Symul L, Wong RJ, Shaw GM et al. Abrupt perturbation and delayed recovery of the vaginal ecosystem following childbirth. Nat Commun. 2023;14(1):4141. https://doi.org/10.1038/s41467-023-39849-9.

17. Wu LY, Yang TH, Ou YC, Lin H. The role of probiotics in women’s health: An update narrative review. Taiwan J Obstet Gynecol. 2024;63(1):29–36. https://doi.org/10.1016/j.tjog.2023.09.018.

18. Stabile G, Topouzova GA, De Seta F. The role of microbiota in the management of genitourinary syndrome of menopause. Climacteric. 2023;26(4):353–360. https://doi.org/10.1080/13697137.2023.2223923.

19. Kutsenko II, Borovikov IO, Kravtsova EI, Avakimyan AA, Borovikova OI, Andreeva AA. The changes in the landscape of the vaginal microbiome in patients undergoing complex treatment for mixed recurrent vaginal infections. Akusherstvo i Ginekologiya (Russian Federation). 2024;(3):153–162. (In Russ.) https://doi.org/10.18565/aig.2024.67.

20. Vogedel EV, Kastelein AW, Jansen CH, Limpens J, Zwolsman SE, Roovers JW et al. The effects of oestrogen on vaginal wound healing: a systematic review and meta-analysis. Neurourol Urodyn. 2022;41(1):115–126. https://doi.org/10.102/nau.24819.

21. Mueck AO, Ruan X, Prasauskas V, Grob P, Ortmann O. Treatment of vaginal atrophy with estriol and lactobacilli combination: a clinical review. Climacteric. 2018;21(2):140–147. https://doi.org/10.1080/13697137.2017.1421923.

22. Радзинский ВЕ, Оразов МР (ред.). Антиэйдж-гинекология. Эволюция и революция. М.: StatusPraesens; 2025. 336 с.