New Treatments for Vaginal Health. Sarah Azad, MD El Camino Women s Medical Group

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1 New Treatments for Vaginal Health There s Hope Sarah Azad, MD El Camino Women s Medical Group

2 The Genitrourinary Syndrome of Menopause (GSM) Problems with genital health secondary to the changes that occur in a woman's body after breast cancer treatment or during menopause. -Millions affected, few seek help

3 It refers to changes in gynecologic health and it happens to a majority of women. As many as 50% of 64 million women are suffering from changes in their gynecologic health 1,2,3

4 Scope - It's estimated by 2025, 1.1 billion women over 50 will be affected Symptoms - Physical (Women's Health Initiative Study) - Vaginal dryness - Irritation, itching, discharge - Pain with intercourse - Frequent urination, loss/leaking of urine - Pelvic floor relaxation - unlike hot flashes and other menopausal symptoms, GSM does not spontaneously remit - GSM symptoms get worse with time

5 Scope - It's estimated by 2025, 1.1 billion women over 50 will be affected Symptoms - Social (From the Vaginal Health: Insights, Views, and Attitudes survey) - Negative impact on one's life/ decreased libido (80%) - Negative consequences in their sexual life (75%) - Negative effects on their marriage or relationship (33%) - Negative impact on self esteem(26%)

6 What Happens: Loss of Estrogen Vagina loses elasticity, shortens, narrows & easily traumatized Loss of rugae, cervix becomes flush with vaginal walls Petechiae may be present ph greater than 5.0, parabasal cells dominate Repopulation with diverse vaginal flora leads to frequent UTIs Worse with chemo (Tamoxifen, aromatase inhibitors, etc)

7 Well-estrogenized Premenopausal State Low-estrogen Postmenopausal State Courtesy of the Graphic Courtesy Dr. Diane Todd Pace NP from the North American Menopause Society

8 Gandhi J, Chen A, Dagur G, et al. Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. Am J Obstet Gynecol. 2016;215(6):

9 What s A Girl To Do? 5 Major Treatment Categories - Regular vaginal stimulation - Over the counter products - Prescription hormone treatments - Ospemifene - Vaginal laser treatments

10 Regular vaginal stimulation Regular (2-3 times/week) sexual arousal promotes bloodflow Regular sexual activity Regular masturbation or use of a vibrator Regular vaginal dilation helps prevent narrowing of the canal Regular vaginal penetrative sexual activity Use of a dilator

11 Vaginal Dilators Easy to purchase privately online Allow for gradual dilation of an already narrowed vagina Once penetration of desired size is comfortable, Continue 2-3 times a week for 5-10 minutes Traditional dilators: increase by 2-7 mm each size can use with any lubricant Newer Milli dilator: inflates by 1 mm increments cannot use with silicone lubricants

12 Over The Counter Lubricants - Regular moisturizer best for persistent dryness - Replens, RepHresh, used 2-3/week - Lubricants also needed with intercourse - Water based, oil based, silicone based - Benefits: cheap, accessible, no systemic affects - Downside: regular use, can be messy

13 Vaginal Estrogens - Now come in many different forms; suppositories, creams, rings, etc. - Must use 2-3 times weekly (except rings) or they stop working - Benefits: have been in use for many years, safe for most women - Downside: can be messy, can be expensive, requires regular use - For women with a history of cancer, may not be candidates

14 DHEA Vaginal Ovules - Intrarosa (prasterone) recently FDA approved for the treatment of moderate to severe pain with intercourse - Vaginal pill, once a day - Benefits: vaginal use, safe for most women - Benefits seen in 2 weeks, does not affect uterus - Affordable with coupon card for commercially insured patients - Downside: can be messy, can be expensive, must use daily - Not studied in women with breast cancer - Can be expensive, not yet covered by Medicare

15 Ospemifene - Selective Estrogen Receptor Modulator (SERM) approved for pain with sex - Prescription medication with estrogen agonist and antagonist actions in the body - Daily oral tablet - Pro-estrogen effect in the vagina and bone - Minimally pro-estrogenic in the uterus - Anti-estrogen effect in the breast - See full effect after 12 weeks of use

16 Ospemifene - Benefits: - Study group followed for a year, found to have good efficacy and safety results - Daily oral tablet - Promising data for breast cancer survivors - Downside: - Side effects: hot flashes, vaginal bleeding and endometrial hyperplasia - Not yet approved in breast cancer patients - Cannot be taken concurrently with Tamoxifen - Slight increased risk of venous thrombosis - Can be expensive

17 Fractional CO2 Laser Treatments - Nonsurgical, outpatient procedure - Clinically proven to bring long-lasting relief - Overwhelming positive and immediate results - Less than 1% of reported side effects - Thousands of women treated since Approved in the US late 2014

18 Fractional CO2 Laser Treatments - Procedure: - In office - Three treatments, each 6 weeks apart - No anesthesia needed for internal treatment - Topical lidocaine needed for external treatment - Visit time between minutes - Maintenance: - One treatment a year (on average)

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20 Fractional CO2 Laser Treatments - Benefits: - Minimal side effects - No downtime - Treatments have lasting effects - No further need for vaginal estrogens - Downsides: - Cost, not covered

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22 Clinically Proven to bring long-lasting relief. A multicenter trial 1 of menopausal women and breast cancer survivors who were treated with MonaLisa Touch observed: Overwhelmingly positive and immediate results Highly statistically significant improvement in symptoms (including dryness, pain, itching, painful urination and painful intercourse) after first treatment No reported side effects or adverse reactions Escalation of progress with each subsequent treatment

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