Current non-hormonal therapy options for vaginal dryness and genitourinary menopausal syndrome: clinical data and practical algorithm

Background. Vaginal dryness is a prevalent condition among women of all ages and can occur not only during menopause as part of the genitourinary syndrome, but also in women of reproductive age, affecting them during the postpartum period and lactation, or due to stress, low body weight, intense physical activity, and the use of certain medications.Reduced vaginal hydration is accompanied by the disruption of the vaginal epithelial barrier, alterations in vaginal pH and microbiota composition, resulting in symptoms of vaginal dryness, burning, pruritus, and dyspareunia, thereby reducing patients' quality of life.
Materials and methods. This article provides an analysis of current non-hormonal approaches to the management of vaginal dryness, including the use of moisturizers based on hyaluronic and lactic acids, and phytocomponents. The mechanisms of action of these components, their effects on restoring vaginal mucosal hydration, maintaining physiological pH, and normalizing the vaginal microbiome were reviewed. Particular attention is given to the role of lactic acid as a component of vaginal moisturizers, which promotes the maintenance of an acidic environment and the growth of Lactobacillus.
Results. The summarized results of clinical trials revealed reduction in VAS scores, an increase in the vaginal health index, normalization of pH, and the an increase in lactoflora counts after non-hormonal treatment courses. Routine combined use of moisturizers promotes vaginal structural repair and functional recovery and demonstrates a favourable safety profile, including patients with contraindications to hormonal therapy. A practical algorithm for the management of patients with vaginal dryness has been proposed, including diagnosis, selection of non-hormonal therapy, treatment efficacy monitoring, and maintenance therapy to prevent symptom recurrence.
Conclusion. The results obtained соnfirm that treatment with non-hormonal moisturizers is an efficient and safe therapeutic option for the improvement of vaginal dryness in women of all ages and can be considered a first-line treatment.

1. Portman D. J., Gass M. L. S. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy. Menopause. 2014; 21 (10): 1063-1068.

2. Mac Bride M. B., Rhodes D. J., Shuster L. T. Vulvovaginal atrophy. Mayo Clin Proc. 2010; 85 (1): 87-94.

3. Nappi R. E., Palacios S. Impact of vulvovaginal atrophy on sexual health. Climacteric. 2014; 17 (1): 3-9.

4. Castelo-Branco C., Cancelo M. J., Villero J., Nohales F., Julia M. D. Management of post-menopausal vaginal atrophy and atrophic vaginitis. Maturitas. 2005; 52 (S1): S46-S52.

5. Kingsberg S. A., Wysocki S., Magnus L., Krychman M. L. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE survey. J Sex Med. 2013; 10 (7): 1790-1799.

6. The North American Menopause Society (NAMS). The 2020 Genitourinary Syndrome of Menopause Position Statement of The North American Menopause Society. Menopause. 2020; 27 (9): 976-992.

7. Hillard T., Panay N. Practical management of genitourinary syndrome of menopause. Climacteric. 2018; 21 (4): 341-346.

8. Tikhomirova E. V. Estrogial: Anti-Aging Strategy for Vaginal Rejuvenation: A Review of Topical Hyaluronic Acid and Phytoestrogens. (In Russ.)

9. Simon J. A., Goldstein I., Kim N. N., Clayton A. H., Kingsberg S. A. The role of androgens in the treatment of genitourinary syndrome of menopause. Menopause. 2018; 25 (7): 837-847.

10. Le Donne M., Caruso C., Mancuso A., et al. The effect of vaginally administered hyaluronic acid on vaginal dryness. Eur Rev Med Pharmacol Sci. 2011; 15 (7): 837-841.

11. Boskey E. R., Cone R. A., Whaley K. J., Moench T. R. Origins of vaginal acidity: high D/L lactate ratio is consistent with bacteria being the primary source. Hum Reprod. 2001; 16 (9): 1809-1813.

12. O’Hanlon D. E., Moench T. R., Cone R. A. Vaginal pH and microbicidal lactic acid when lactobacilli dominate the microbiota. PLoS One. 2013; 8 (11): e80074.

13. Jokar A., Davari Tanha F., Ghasemi M. Comparison of the effect of hyaluronic acid vaginal cream and conjugated estrogen in the treatment of vaginal atrophy. J Menopausal Med. 2016; 22 (2): 104-108.

14. Ermakova E. I., Smetnik A. A. Experience of clinical application of nonhormonal vaginal cream for the treatment of genitourinary menopausal syndrome/vulvovaginal atrophy in patients with estrogendependent oncologic diseases in anamnesis. Akusherstvo i ginekologiya. 2023; 8: 167-176. (In Russ.)

15. Chernova N. I., Arutyunyan E. Current aspects of treatment in patients with dystrophy and atrophy of the intimate area. What is new? Rossiiskii vestnik akushera-ginekologa. 2018; 18 (3): 95-98. (In Russ.)

16. Tan O., Bradshaw K., Carr B. R. Management of vulvovaginal atrophy-related sexual dysfunction. Menopause. 2012; 19 (1): 109-117.

17. Parish S. J., Nappi R. E., Krychman M. L., et al. Impact of vulvovaginal health on sexual function in women. J Sex Med. 2013; 10 (7): 1790-1799.

18. Palma F., Volpe A., Villa P., Cagnacci A. Vaginal atrophy of women in postmenopause: results from the AGATA study. Maturitas. 2016; 83: 40-44.

19. Chen J., Geng L., Song X., Li H., Giordan N., Liao Q. Evaluation of the efficacy and safety of hyaluronic acid vaginal preparations in the treatment of vaginal dryness: systematic review and meta-analysis. Menopause. 2013; 20 (10): 1099-1105.

20. Stika C. S. Atrophic vaginitis. Dermatol Ther. 2010; 23 (5): 514-522.

21. Witkin S. S., Linhares I. M., Giraldo P. Bacterial flora of the female genital tract: function and immune regulation. Best Pract Res Clin Obstet Gynaecol. 2007; 21 (3): 347-354.

22. Edwards D., Panay N. Treating vulvovaginal atrophy/genitourinary syndrome of menopause. Women’s Health. 2016; 12 (3): 321-326.

23. Ekin M., Yaşar L., Savan K., et al. The comparison of hyaluronic acid vaginal tablets and estradiol vaginal tablets in the treatment of vaginal atrophy. Arch Gynecol Obstet. 2011; 284 (2): 539-543.

24. World Health Organization. WHO guidelines on the safety of vaginal lubricants. Geneva: WHO; 2012.