Painful vaginal and vulvar conditions can be difficult to resolve successfully without a comprehensive treatment plan. These conditions are challenging for practitioners because age, hormonal status, dysbiosis, traumatic events, mental health, genetics, and general state of health represent only a few factors that may need to be addressed. This group of disorders often causes a reduction in quality of life for the patients experiencing them. Fortunately, there are unique customizable treatment options that our compounding lab can offer to patients with atrophic vaginitis, vulvar lichen sclerosis, desquamative inflammatory vaginitis, vaginismus, vulvodynia, and high-tone pelvic floor dysfunction.
Atrophic vaginitis, or vaginal atrophy, is possibly the most common vaginal condition facing post-menopausal and perimenopausal women. It is characterized by vaginal dryness, thinning of the vaginal mucosa, and, in some cases, inflammation and bleeding. Atrophic vaginitis is a condition caused by estrogen deficiency and can also occur in patients following radiation therapy, chemotherapy, removal of one or both ovaries, premature ovarian failure, or endocrine disorders as well as in patients receiving anti-estrogen medication. Atrophic vaginitis can cause painful intercourse and burning pain and—if not addressed—can lead to other symptoms including urinary symptoms.
Treatment with intravaginal estrogen creams, gels, and inserts (specifically estradiol) are the gold standard treatment. Unfortunately, this therapy is not the best therapeutic option for every patient. Estriol or hyaluronic acid may be an alternative for patients who are not good candidates for intravaginal estradiol. In a phase III study, 167 patients received either 1gm of vaginal gel containing 50μg of estriol or placebo. Patients were instructed to use the gel daily for three weeks and then twice weekly up to 12 weeks. The results of this study support the use of estriol in women with atrophic vaginitis. Estriol was superior to the placebo in reducing vaginal dryness, atrophy, dyspareunia, pruritis, burning, vaginal pH, and painful urination. This option could be a potential alternative for those patients who respond to estrogen therapy but may be sensitive to more potent estrogens such as estradiol.
Patients who have a personal history of estrogen-receptor-positive cancer, who have a high risk of such cancer types or who are receiving antiestrogen medication will need alternative treatment options. Hyaluronic Acid (HA) is a naturally occurring substance that’s found in the fluids of the eyes and joints. HA hydrates and refreshes the vaginal tissue in a hormone-free way. Each molecule of HA attracts and retains up to 1,000 times its weight in moisture. This helps to heal the thinning and damaged skin inside the vaginal walls. And, since HA is a naturally occurring substance, it is generally considered to be completely safe for use.
Vulvar Lichen Sclerosis
Vulvar lichen sclerosis (VLS) is a chronic inflammatory disorder of unknown cause and can affect women of all ages. The risk factors include genetic predisposition, autoimmunity, repeated tissue trauma, infection, and low hormone levels. VLS is characterized by atrophic, white plaques that cause pruritis, pain, burning, and potentially genital scarring and adhesion if not treated effectively and early. It is typically isolated to the labial, perineal, and perianal areas, but in some patients, other areas such as the trunk, buttock, and thigh can be involved. VLS has also been associated with an increased risk of squamous cell carcinoma. VLS has at least in part an autoimmune etiology.
While high-dose topical steroids such as mometasone furoate 0.05% or clobetasol propionate 0.05% are the current mainstay of treatment, there are other options for patients who do not improve with this treatment. A 0.1% tacrolimus ointment has been shown to help many patients with anogenital involvement but does not work so well in patients with extragenital involvement.
Naltrexone may be another topical option for these patients. Naltrexone can inhibit the pro-duction of inter-leukin-6 and TNF-A, which are part of the pathogenic picture of many inflammatory conditions, including VLS. Although there are no large-scale trials, topical naltrexone has been used successfully in other autoimmune diseases and may be worth considering.
If you believe one of these custom compounded solutions would be helpful, please have your physician call us or stop by to pick up an informational sheet to take to your doctor.