What are the recommended first-line treatments for atrophic vaginitis in postmenopausal women?

First-line treatment for atrophic vaginitis in postmenopausal women is the use of vaginal oestrogen therapy. Vaginal oestrogen can be administered as creams, gels, tablets, pessaries, or rings, and it acts locally with minimal systemic absorption, making it effective and generally safe for managing genitourinary symptoms associated with menopause, including atrophic vaginitis ¹.

When vaginal oestrogen is contraindicated or declined by the patient, non-hormonal vaginal moisturisers or lubricants are recommended as alternative first-line options. These can be used alone or in combination with vaginal oestrogen if tolerated ¹.

For cases where vaginal oestrogen and non-hormonal treatments are ineffective or not tolerated, vaginal prasterone or oral ospemifene may be considered as subsequent options. However, these are not first-line treatments ¹.

It is important to note that vaginal laser therapy is not recommended outside of clinical trials due to insufficient evidence of benefit and safety ¹.

From the literature perspective, resistance and barriers to local estrogen therapy have been identified, including patient concerns about hormone use and lack of awareness, which may affect adherence and acceptance of vaginal oestrogen treatment (Kingsberg and Krychman, 2013). This underscores the importance of patient education and shared decision-making when initiating treatment.