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Vulvovaginal atrophy

Key sources
The following summarized guidelines for the evaluation and management of vulvovaginal atrophy are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2021; 2014), the Endocrine Society (ES 2015), the American College of Obstetricians and Gynecologists (ACOG 2014), the North American Menopause Society (NAMS 2013), and the American Association of Clinical Endocrinologists (AACE 2011).
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Guidelines

1.Screening and diagnosis

Indications for screening: as per SOGC 2021 guidelines, obtain comprehensive screening for genitourinary syndrome of menopause symptoms on an ongoing basis in menopausal females, as symptoms can present insidiously and become bothersome long after the menopausal transition.
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2.Diagnostic investigations

Evaluation of vaginal bleeding: as per ES 2015 guidelines, obtain evaluation to rule out pelvic pathology, most importantly, endometrial hyperplasia and cancer in patients with persistent unscheduled bleeding while taking menopausal hormone therapy.
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  • Evaluation of sexual dysfunction

3.Medical management

Vaginal lubricants and moisturizers: as per SOGC 2021 guidelines, consider offering vaginal lubricants and moisturizers for the treatment of vaginal atrophy related to menopause.
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  • Local estrogen therapy

  • Systemic estrogen therapy

4.Therapeutic procedures

Vaginal laser therapy: insufficient evidence regarding the long-term use of intravaginal laser therapy for the management of genitourinary syndrome of menopause outside of a clinical trial.
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5.Specific circumstances

Patients with breast cancer
As per SOGC 2014 guidelines:
Discuss quality-of-life considerations when considering the use of intravaginal estrogen therapy for severe vulvovaginal atrophy in patients with breast cancer, as well as the uncertainty regarding effects on breast cancer recurrence.
B
Discuss the uncertainty of risks associated with systemic hormone therapy after a diagnosis of breast cancer in patients seeking treatment for distressing symptoms (vasomotor symptoms or vulvovaginal atrophy).
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  • Patients with endometrial cancer

  • Patients with hormone-independent cancer

6.Patient education

General counseling: provide proactive education on vaginal health in postmenopausal females.
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