Treatment action Topical/Behavioral Vaginal meds Testing/Notes
Comfort measures, general care Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants, daily panty liners, or tight clothing, application of cool gel packs; Use of topical moisturizer every three days: Vaseline or Replens. Atrophy is diagnosed primarily with the history, exam, vaginal pH, and microscopy. Oral hormone replacement therapy is not necessary (and often does not work) for improvement of symptoms related to vulvovaginal atrophy. Absorption of vaginal estrogen does occur but does not approach pre-menopausal levels. ( LINK to Annotation P, pH values)
Increased comfort with vaginal penetrative sex Use of lubricant with intercourse: vegetable oil, mineral oil, Astroglide, or SlipperyStuff, (the latter two safe for use with condoms) (LINK to LUBRICANTS) Topical xylocaine 5%, approximately 1 inch of ointment applied to vaginal opening, avoiding clitoris, for 10-15 minutes prior to sex. Wipe off first and then apply a lubricant. (Use no more than 15 grams a day). Warn patient that xylocaine stings when first applied.
Local estrogen replacement in the vagina (lowest to highest doses) Vagifem tablets, 10 mcg intravaginally nightly for 7-14 days, then twice weekly
(total 20 mcg/week)
Estring, vaginal ring, 7.5 mcg/24 hr inserted vaginally once every 90 days (total 52.5 mcg/week)
Estrace cream, (100 mcg estradiol/1g cream): 0.5 gm intravaginally, nightly for 7 days then twice weekly
(total 100 mcg/week for maintenance)
Premarin cream, (0.625 mg conjugated estrogens/1 g cream): 0.5 gm intravaginally, nightly for seven days, then twice weekly (total 600 mcg/week)
*The original Vagifem dose was 25 mcg twice weekly for maintenance. The company lowered the dose to 10 mcg twice weekly and this is usually sufficient, but not always. Some women respond better to 10 mcg three times a week and some need the addition of topical Estrace cream, ¼ tsp, applied to the vaginal opening twice weekly. Traditional dosing for the vaginal creams has been 1 gm vaginally twice a week for maintenance. Many clinicians have found that 0.5 gm twice weekly is enough.
For ongoing pain, with or without intercourse, despite the above treatments Try adjunctive ¼ tsp of Estrace or Premarin cream topically applied to the vaginal opening nightly for 7 days, then 2-3 times a week. (This is usually temporary. The vaginal estrogen usually suffices for comfortable intercourse.)
Consider pain from another condition: irritants, yeast infection, dermatosis, pelvic floor dysfunction, vulvodynia. Evaluate and treat appropriately.

Updated 7/11/14 vaginal atrophy in Atlas and in Annotation