The effect of oxytocin vaginal gel on vaginal atrophy in postmenopausal women: a randomized controlled trial

The Effect of Citrus Aurantium Vaginal Cream on Vaginal Atrophy in Postmenopausal Women: A Quasi-experimental Study

Background

Vulvovaginal atrophy (VVA) is a common condition and a silent epidemic affecting many postmenopausal women who suffer from it in silence. This study aimed to evaluate the effect of Citrus aurantium vaginal cream on vaginal atrophy in postmenopausal women.

Methods

This single-group pretest-posttest quasi-experimental study was conducted on 30 postmenopausal women who were referred to the Gynecology Clinic of Imam Khomeini Hospital in the city of Noor, Iran, from June to November 2020. Citrus aurantium vaginal cream was administered to women diagnosed with vaginal atrophy (based on subjective symptoms of atrophy, descriptive evaluation of the vagina, vaginal pH measurement, and degree of vaginal maturation determined by vaginal smear) every night in the first two weeks and every other night for the second two weeks. Data were collected using the scale of subjective symptoms of vaginal atrophy; descriptive evaluation checklist of vaginal mucosa; laboratory results registration form (vaginal maturation index, vaginal maturation value, and vaginal pH) before the intervention and two and four weeks after the intervention. Data were analyzed using SPSS software (version 24) through the analysis of variance with repeated measurements, and LSD post-hoc test. A P value less than 0.05 (P<0.05) was considered statistically significant.

Results

Citrus aurantium vaginal cream improved subjective symptoms of vaginal atrophy (P<0.001), reduced the score of descriptive evaluation of vaginal mucosa (P<0.001), decreased vaginal pH (P<0.001), and increased vaginal maturity (P<0.001).

Conclusions

The results showed that citrus aurantium vaginal cream could improve the symptoms of vaginal atrophy without causing serious complications. However, further studies with a control group are suggested to confirm the findings of this study.Trial Registration Number: IRCT20200215046494N.

The efficacy of oxytocin gel in postmenopausal women with vaginal atrophy: an updated systematic review and meta-analysis

BACKGROUND

Genitourinary syndrome of menopause (GSM) is a common and disturbing issue in the postmenopausal period. Unlike vasomotor symptoms, it has a progressive trend. Our study aims to evaluate the efficacy and safety of oxytocin gel versus placebo gel in postmenopausal women with GSM.

METHODS

A systematic review and meta-analysis synthesizing randomized controlled trials (RCTs) from Web of Science, SCOPUS, PubMed, and Cochrane Central Register of Controlled Trials databases on January 18, 2023. Keywords such as "oxytocin," "intravaginal," "vaginal," "atrophic," and "atrophy" were used. We used Review Manager (RevMan) version 5.4 in our analysis. We used the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes; both were presented with the corresponding 95% confidence interval (CI) and were calculated with the Mantel-Haenszel or inverse variance statistical method. Cochrane's Q test and the I2 statistic were used as measures of statistical inconsistency and heterogeneity. The Cochrane Risk of Bias Tool for RCTs was used for the quality assessment of the included studies.

RESULTS

Seven studies with 631 patients were included. Regarding the maturation index, there was a statistically insignificant increase in the oxytocin arm (MD = 12.34, 95% CI (-12.52-37.19), P = 0.33). Clinically assessed vaginal atrophy showed a statistically significant reduction in the oxytocin group (RR = 0.32, 95% CI (0.23 - 0.10), P < 0.00001). For dyspareunia, vaginal pH, and histological evaluation of vaginal atrophy, there was a statistically insignificant difference between the two groups (RR = 1.02, 95% CI (0.82-1.27), P = 0.84), (MD = -0.74, 95% CI (-1.58-0.10), P = 0.08), and (MD = -0.38, 95% CI (-0.82-0.06), P = 0.09), respectively. There was no significant difference in the safety profile between the two groups as measured by endometrial thickness (MD = 0.00, 95% CI (-0.23-0.23), P = 0.99).

CONCLUSIONS

Although oxytocin has been proposed as a viable alternative to estrogen in the treatment of GSM, our findings show the opposite. Larger, high-quality RCTs are needed to confirm or refute our results.

TRIAL REGISTRATION

PROSPERO registration number CRD42022334357.

Effect of folic acid on the sexual function of postmenopausal women: a triple-blind randomized controlled trial

BACKGROUND

There are reports of sexual dysfunction in postmenopausal women, and several treatment recommendations are available.

AIM

To investigate the effect of folic acid on postmenopausal women's sexual function.

METHODS

This triple-blind randomized controlled trial was conducted in Tehran, Iran, in 2020. A sample of 100 postmenopausal women was recruited from comprehensive health centers affiliated with the Shahid Beheshti University of Medical Sciences. Eligible women were randomly assigned to receive folic acid (5 mg) or placebo on an empty stomach every day for 8 weeks. Women were assessed at 3 time points: baseline and 4 and 8 weeks after the intervention.

OUTCOME

Sexual function was the main outcome, as measured by the Female Sexual Function Index.

RESULTS

The mean ± SD age of participants in the folic acid and placebo groups was 53.2 ± 3.84 and 54.4 ± 4.05 years, respectively (P = .609). The results obtained from mixed effects analysis of variance revealed a statistically significant difference between baseline and posttreatment scores and the interaction between time and group for desire, orgasm, satisfaction, arousal, pain, and total sexual function score, with the folic acid group improving more than control group. Lubrication was the only domain that showed no significant difference for the interaction between time and group.

CLINICAL IMPLICATIONS

Folic acid may beneficially affect sexual function in postmenopausal women.

STRENGTHS AND LIMITATIONS

Strengths include the novelty of the subject, the triple-blind design, the block randomization, the administration of a standard scale for sexual function (Female Sexual Function Index), and the affordability and availability of folic acid. This study was conducted with a small sample size and short follow-up time; therefore, interpretation of the results requires great caution.

CONCLUSION

The findings suggest that folic acid possibly improves sexual function in postmenopausal women. Larger studies are needed to confirm the findings.

TRIAL REGISTRATION

IRCT20150128020854N8; August 2, 2020. Iranian Registry of Clinical Trials; https://en.irct.ir/user/trial/48920/view.

Effect of topical oxytocin gel on vaginal mucosa in postmenopausal Egyptian women: a clinical randomized trial

BACKGROUND

Vaginal atrophy is common after menopause and is often linked to sexual dysfunction, particularly dyspareunia.

AIM

The study aimed to investigate the effect of intravaginally applied oxytocin on expressions of vaginal atrophy.

METHODS

Fifty postmenopausal women aged 47 to 66 years with vaginal atrophy participated in this double-blinded placebo-controlled study. The women were randomized to intravaginal treatment with either gel with 600 IU/mL of oxytocin (oxytocin group) or gel alone (control group) once daily for 2 weeks. The gel consisted of hypromellose, pH 3.8 (Vagovital).

OUTCOMES

The color of the vaginal mucosa, the vaginal pH, and the cytology of vaginal epithelial cells were investigated before and after treatment.

RESULTS

The color of the vaginal mucosa shifted from pale to red in all 25 patients treated with oxytocin but only in 4 patients in the control group (P < .001). There was a significant decrease in intravaginal pH in the oxytocin group and the control group, with the delta value being significantly greater in the oxytocin group than in the control group (P < .001). The vaginal maturation index increased significantly (P < .001) in the oxytocin group but not in the control group.

CLINICAL IMPLICATIONS

Topical oxytocin gel offers an effective solution to the sexual dysfunction that is related to vaginal atrophy after menopause.

STRENGTHS AND LIMITATIONS

Strengths include studying different outcomes of applying the oxytocin gel for vaginal atrophy. Limitations include the small-scale population with a relatively short duration of treatment (2 weeks).

CONCLUSION

Intravaginal treatment with a gel containing 600 IU/mL of oxytocin effectively counteracts physical expressions of vaginal atrophy.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05275270; https://clinicaltrials.gov/ct2/show/NCT05275270).

Pharmacotherapy for female sexual dysfunctions (FSDs): what is on the market and where is this field heading?

INTRODUCTION

Female sexual dysfunctions (FSDs) are common in women of any age and have a huge impact on quality of life and relationships. They have a multifaceted etiology limiting the development of pharmacotherapies with a high rate of effectiveness. Safety issues are also a concern.

AREAS COVERED

The authors report the most recent advances in pharmacotherapy for premenopausal and postmenopausal women with a main focus on hypoactive sexual desire disorders (HSDD) and associated sexual symptoms. Good levels of evidence have emerged for psychoactive agents, such as flibanserin and bremelanotide, as well as hormonal compounds (transdermal testosterone). The authors also report briefly on intravaginal DHEA (prasterone), local estrogen therapy (LET), and ospemifene to manage effectively vulvovaginal atrophy/genitourinary syndrome of menopause (VVA/GSM). In addition, they discuss promising therapeutic options highlighting the main reasons that hamper the availability of new labeled products. Finally, they include the importance of the multimodal approach to address FSDs.

EXPERT OPINION

Approved pharmacotherapies for FSD are limited. Validated multidimensional instruments and adequate objective measures of physical and mental responses to sexual external and internal incentives are mandatory to identify women suitable to chronic or on-demand treatments and to assess their pattern of response in research and practice.

The effects of moderate-intensity step-aerobics, spinning, and educational game exercise programs on plasma dopamine and oxytocin levels in women in the menopausal transition period

Background/Aim: Menopausal transition (MT) is defined as the transition from reproductive to post-reproductive life. Oxytocin has beneficial effects on health problems, such as sexual activity disorder, vaginal atrophy, cardiovascular system diseases and acceleration in bone mass loss, which may develop due to changes in reproductive hormone levels during the MT period. During exercise, which can be used as adjuvant therapy for most of these health problems, a temporary increase in catecholamine levels is required for response to exercise-induced stress. However, the effects of exercise programs applied during the MT period on plasma dopamine (pDA) and plasma oxytocin (pOT) levels are unknown. The aim of this study was to investigate the effects of three different types of exercise on plasma dopamine (pDA) and plasma oxytocin (pOT) levels in sedentary women in the MT period. Methods: Twenty-six sedentary healthy participants in the MT period whose fitness levels in the standard maximal exercise treadmill test were at a level that would complement the exercise programs in our study, were included in the study. Participants with the following conditions were excluded from the study: physical disability that would not allow exercise, systemic disease, unilateral oophorectomy, or history of smoking. In addition, participants who could not complete any of the exercise programs for any reason were excluded from the study. Three different exercise programs at moderate intensity [maximum heart rate (HR) = 50%-60%] of 60 minutes duration were performed by the participants at one-week intervals: (i) step-aerobics (SA), (ii) spinning (SP) and (iii) station work in the form of recreational educational games (EG). pOT and pDA levels were measured using the enzyme-linked immunosorbent assay method in venous blood samples taken from participants before the exercise and during the last five minutes of the exercise. pOT and pDA levels measured before the exercise and in the last five minutes of the exercise were compared. Results: The median age was 45 (41-45) and the body mass index (BMI) was 29 (27-34). There was a significant increase in mean pDA levels during exercise compared to pre-exercise in all three activities of moderate-intensity, SA, SP, and EG (P = 0.008, P = 0.001 and P = 0.030, respectively). The mean pOT level increased significantly during moderate-intensity SA and EG (P = 0.003 and P = 0.001, respectively). When the relationships between pDA and pOT levels and the variables of age, BMI, pulse rate, and maximum HR during all three exercises were evaluated, there was a significant positive correlation between pOT levels and maximum HR only during EG (r = 0.439, P = 0.028). Conclusions: This study showed that SA and EG applied in women in the MT period increased both pDA and pOT levels, while SP only increased the pDA level significantly. Therefore, SA and EG exercises can contribute positively to the quality of life of women with health problems due to low pOT levels during the MT period.

Possible cytoprotective mechanisms of oxytocin against 5-fluorouracil-induced gastrointestinal mucositis

Gastrointestinal mucositis is a common and dose-limiting side effect characterized by ulcerative lesions in the mucosa of the digestive tract in patients receiving anticancer drugs such as 5-fluorouracil (5-FU), a potent antineoplastic drug. Several protocols have reported the efficacy of therapeutic interventions to prevent this side effect, although complete success has not yet been achieved and mucositis remains one of the most serious complications associated with 5-FU therapy. Oxytocin, a well-known antistress agent, has been reported to have comparable effects to ranitidine. Previous studies have shown that oxytocin inhibits gastric acid secretion and the expression of proinflammatory cytokines in rats. If oxytocin can reduce stress-induced ulcers via antioxidant, antiapoptotic, and anti-inflammatory pathways, then it may have a dose-dependent effect on gastrointestinal mucositis caused by 5-FU.

Oxytocin in Women's Health and Disease

Oxytocin (OT) is a nonapeptide mainly produced in the supraoptic and paraventricular nuclei. OT in the brain and blood has extensive functions in both mental and physical activities. These functions are mediated by OT receptors (OTRs) that are distributed in a broad spectrum of tissues with dramatic sexual dimorphism. In both sexes, OT generally facilitates social cognition and behaviors, facilitates parental behavior and sexual activity and inhibits feeding and pain perception. However, there are significant differences in OT levels and distribution of OTRs in men from women. Thus, many OT functions in men are different from women, particularly in the reproduction. In men, the reproductive functions are relatively simple. In women, the reproductive functions involve menstrual cycle, pregnancy, parturition, lactation, and menopause. These functions make OT regulation of women's health and disease a unique topic of physiological and pathological studies. In menstruation, pre-ovulatory increase in OT secretion in the hypothalamus and the ovary can promote the secretion of gonadotropin-releasing hormone and facilitate ovulation. During pregnancy, increased OT synthesis and preterm release endow OT system the ability to promote maternal behavior and lactation. In parturition, cervix expansion-elicited pulse OT secretion and uterine OT release accelerate the expelling of fetus and reduce postpartum hemorrhage. During lactation, intermittent pulsatile OT secretion is necessary for the milk-ejection reflex and maternal behavior. Disorders in OT secretion can account for maternal depression and hypogalactia. In menopause, the reduction of OT secretion accounts for many menopausal symptoms and diseases. These issues are reviewed in this work.

Neural Functions of Hypothalamic Oxytocin and its Regulation

Oxytocin (OT), a nonapeptide, has a variety of functions. Despite extensive studies on OT over past decades, our understanding of its neural functions and their regulation remains incomplete. OT is mainly produced in OT neurons in the supraoptic nucleus (SON), paraventricular nucleus (PVN) and accessory nuclei between the SON and PVN. OT exerts neuromodulatory effects in the brain and spinal cord. While magnocellular OT neurons in the SON and PVN mainly innervate the pituitary and forebrain regions, and parvocellular OT neurons in the PVN innervate brainstem and spinal cord, the two sets of OT neurons have close interactions histologically and functionally. OT expression occurs at early life to promote mental and physical development, while its subsequent decrease in expression in later life stage accompanies aging and diseases. Adaptive changes in this OT system, however, take place under different conditions and upon the maturation of OT release machinery. OT can modulate social recognition and behaviors, learning and memory, emotion, reward, and other higher brain functions. OT also regulates eating and drinking, sleep and wakefulness, nociception and analgesia, sexual behavior, parturition, lactation and other instinctive behaviors. OT regulates the autonomic nervous system, and somatic and specialized senses. Notably, OT can have different modulatory effects on the same function under different conditions. Such divergence may derive from different neural connections, OT receptor gene dimorphism and methylation, and complex interactions with other hormones. In this review, brain functions of OT and their underlying neural mechanisms as well as the perspectives of their clinical usage are presented.

Non-oestrogenic modalities to reverse urogenital aging

Urogenital aging is a common process affecting all women in the post-menopausal period of their life, and it is substantially due to oestrogen deprivation after ovarian function cessation. These changes can lead to a progressive, chronic, and complex association of symptoms identified as the genitourinary syndrome of menopause, which has a significant impact on quality of life. Genitourinary syndrome and urogenital aging do not resolve spontaneously and usually recur when treatment is stopped. Therefore, appropriate long-term management is of paramount importance, and local oestrogen is the most effective treatment to reverse urogenital aging and to improve symptoms of genitourinary syndrome as replacement therapy. In some women, topical oestrogen may be inconvenient, it may not achieve complete response, or it may be contra-indicated. Several non-hormonal therapies have been investigated, but few treatments have been reported as potentially able to reverse the urogenital aging process similarly to exogenous oestrogens. Laser seems the most promising, although further studies to define its safety and efficacy are mandatory. Vitamin D and E, and phytotherapy have returned conflicting results and require further confirmation. Lifestyle modifications, physiotherapy, and electrical stimulation represent inexpensive and applicable treatments that might slow urogenital aging. Among the hormonal non-oestrogenic therapies, the use of vaginal oxytocin and dehydroepiandrosterone have been found to be effective compared to placebo, as well as the use of oral ospemifene, which partially relieves vulvovaginal atrophy.

Vaginal dehydroepiandrosterone compared to other methods of treating vaginal and vulvar atrophy associated with menopause

During the menopause, a fall in estrogen levels often leads to many unfavorable symptoms, including changes in the vascular and urogenital systems, in mood, and sleep. The symptoms of vulvovaginal atrophy are especially troublesome for menopausal women. These symptoms not only disturb the sexual sphere, but also functioning at work and in the family. Based on the literature, a review of contemporary methods of management in the case of symptoms of vulvar atrophy in menopausal women has been performed. The current methods of treating vulvovaginal atrophy in menopausal women are described. The pharmacology of the available dehydroepiandrosterone (DHEA) preparations, both oral and vaginal, was briefly analyzed. Own experiences of using DHEA are presented. Vaginal DHEA has been found to be an effective and safe treatment in menopausal women with symptoms of vaginal atrophy.