Management of Vaginal Atrophy: Implications from the REVIVE Survey

Vulvar and vaginal atrophy (VVA) is a chronic and progressive medical condition common in postmenopausal women. Symptoms of VVA such as dyspareunia, vaginal dryness, irritation, and itching can negatively impact sexual function and quality of life. The REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey assessed knowledge about VVA and recorded attitudes about interactions with healthcare providers (HCPs) and available treatment options for VVA. The REVIVE survey identified unmet needs of women with VVA symptoms such as poor understanding of the condition, poor communication with HCPs despite the presence of vaginal symptoms, and concerns about the safety, convenience, and efficacy of available VVA treatments. HCPs can address these unmet needs by proactively identifying patients with VVA and educating them about the condition as well as discussing treatment preferences and available therapies for VVA.

Overall Safety of Ospemifene in Postmenopausal Women from Placebo-Controlled Phase 2 and 3 Trials

Objective: To evaluate the safety of daily oral ospemifene 60 mg, estrogen agonist/antagonist, used to treat moderate-to-severe dyspareunia due to postmenopausal vulvovaginal atrophy, which is part of genitourinary syndrome of menopause.

Methods:Post hoc analysis of safety data (treatment-emergent adverse events [TEAEs]) pooled from six phase 2 and 3 randomized, double-blind, multicenter placebo-controlled studies, evaluating the effects of ospemifene 60 mg on the breast, cardiovascular system, and bone in postmenopausal women.

Results: At least one TEAE was reported by 67.6% (840/1242) and 54.1% (518/958) of women taking ospemifene 60 mg and placebo, respectively. Most TEAEs were mild or moderate and occurred within 4 to 12 weeks. The most commonly reported TEAEs with ospemifene were hot flush (8.5% vs. 3.3% for placebo) and urinary tract infection (6.5% vs. 4.8%). Discontinuation due to TEAEs was 7.6% with ospemifene and 3.8% with placebo. Most women discontinued treatment due to adverse events (AEs): hot flushes, muscle spasms, headache, and vaginal discharge. Serious AEs occurred infrequently (ospemifene, 2.6%; placebo, 1.8%); most were not considered related to treatment. Breast cancer and other breast-related TEAE incidences were comparable between ospemifene (2.5%) and placebo (2.2%), and cardiovascular TEAE incidence, including deep vein thrombosis, was low with ospemifene (0.3%) and placebo (0.1%).

Conclusion: No unexpected safety signals were reported, and discontinuation due to TEAEs was low, with use of ospemifene 60 mg versus placebo in six phase 2 and 3 trials, suggesting a lack of detrimental effects on the breast, bone, and cardiovascular health of postmenopausal women when ospemifene is used to effectively treat moderate-to-severe postmenopausal dyspareunia.

Tissue selectivity of ospemifene: pharmacologic profile and clinical implications

The multifactorial consequences of menopausal estrogen deficiency affect numerous tissues throughout the body. Supplemental hormonal therapies carry the burden of a risk/benefit ratio that must be highly individualized. Selective estrogen receptor modulators (SERMs) are estrogen receptor (ER) agonist/antagonists designed to induce benefits comparable with estrogen while minimizing adverse effects. Here, we review the estrogen agonist/antagonist profile of ospemifene, a novel triphenylethylene derivative recently approved to treat dyspareunia, a symptom of vulvar and vaginal atrophy (VVA) due to menopause, both preclinically and clinically. Ospemifene binds ERα and ERβ with approximately equal affinities. In preclinical models, ospemifene increased vaginal and uterine epithelial thickness and mucification to the same extent as estrogen. Ospemifene did not induce endometrial hyperplasia in animal models; there also was no stimulatory effect on endometrial cells. In rat and human mammary cells in vitro, ospemifene evokes a dose-dependent inhibition on estrogen-induced cell responses and cell proliferation, supporting an antiestrogenic effect in breast. In contrast, ospemifene has an estrogenic effect on bone, as seen by improved bone mineral density, strength, mass, and histomorphometry in preclinical models, consistent with improvements in markers of bone resorption and formation in postmenopausal women. Based on the preclinical evidence, ospemifene has beneficial estrogen-like effects on the vaginal epithelium, preliminary evidence to support a neutral endometrial profile, antiproliferative effects in breast, and estrogenic effects in bone. Taken together, especially regarding estrogen-like effects on the vaginal epithelium, ospemifene presents a profile of tissue-specific effects that appear novel among available SERMs and well-suited for the treatment of VVA.

Pharmacokinetic studies of solubilized estradiol given vaginally in a novel softgel capsule

Objective To evaluate the bioavailability and safety of a novel vaginal capsule containing solubilized bioidentical 17β-estradiol for vulvar and vaginal atrophy and compare its pharmacokinetics with that of an approved vaginal estradiol tablet in healthy postmenopausal women.

Methods Two randomized, single-dose, two-way cross-over, relative bioavailability trials compared the pharmacokinetics of a solubilized vaginal estradiol softgel capsule (TX-004HR, test) with that of a vaginal estradiol tablet (Vagifem®, reference) in postmenopausal women (aged 40–65 years) at 10-μg and 25-μg doses. In each study, women were randomly assigned to receive a single dose of the test capsule or reference tablet, followed by a single dose of the alternate drug after a 14-day washout.

Results Thirty-five women completed the 10-μg study and 36 completed the 25-μg study. Significantly lower systemic levels of estradiol, estrone, and estrone sulfate at both doses of the test product were observed compared with equivalent doses of the reference product, with lower AUC_0-24 and C_max and earlier t_max. No adverse events were reported in either trial.

Conclusion TX-004HR, a novel estradiol vaginal softgel capsule, exhibited significantly lower systemic exposure than equivalent doses of an approved vaginal estradiol tablet at both 10-μg and 25-μg doses. Both doses of each product were safe and well-tolerated.

Vaginal effects of ospemifene in the ovariectomized rat preclinical model of menopause

Ospemifene is a unique tissue-selective estrogen agonist/antagonist (also known as a selective estrogen receptor modulator [SERM]) with demonstrated efficacy in Phase 3 studies of postmenopausal women with vulvar and vaginal atrophy (VVA). This report describes preclinical studies on the effects of ospemifene in the ovariectomized (OVX) rat model of menopause. Ospemifene (10mg/kg/day) and the SERM comparator, raloxifene (10mg/kg/day) were administered for 2 weeks and both increased vaginal weight; ospemifene was more effective than raloxifene. In addition, ospemifene had a greater effect on increasing vaginal epithelial height compared with raloxifene. The effect on uterine weight was less pronounced for both ospemifene and raloxifene. The ED50 of ospemifene on vaginal epithelial height was 0.39mg/kg/day and the magnitude was nearly the same as was seen with the positive control, 17α-ethinyl estradiol (EE2). In a histological analysis of ospemifene-treated rat vaginas, basal cells were overlaid by 2 to 3 cell layers of thickened goblet-like mucified cells apically; however, the cornification observed with EE2 was absent. Estrogenic activity of ospemifene was confirmed by upregulation of progesterone receptors in vaginal epithelium and stroma. Ospemifene showed similar affinity for estrogen receptor (ER)-α and ER-β, but an overall lower affinity than estradiol. Ospemifene antagonized estrogen response element (ERE)-mediated transactivation on MCF-7 cells, confirming its anti-estrogenic activity in breast cancer cells. The dose response for ospemifene in the rat is consistent with that observed in clinical studies of ospemifene 30 and 60mg, showing that the OVX rat is a highly predictive model of SERM activity in postmenopausal VVA.

Clinical update on the use of ospemifene in the treatment of severe symptomatic vulvar and vaginal atrophy

The physiological decrease in vaginal estrogens is accountable for the emergence of vulvar and vaginal atrophy (VVA) and its related symptoms such as vaginal dryness, dyspareunia, vaginal and/or vulvar irritation or itching, and dysuria. The repercussion of these symptoms on quality of life often makes it necessary to initiate treatment. Up until now, the treatments available included vaginal moisturizers and lubricants, local estrogens, and hormonal therapy. However, therapeutic options have now been increased with the approval of 60 mg ospemifene, the first nonhormonal oral treatment with an agonist effect on the vaginal epithelium and an endometrial and breast safety profile which makes it unique. This is the first selective estrogen receptor modulator indicated in women with moderate-to-severe vaginal atrophy not eligible for local estrogen treatment. Considering that "local estrogen noneligible women" are those in whom such treatment cannot be administered either because it is contraindicated or due to skill issues, who are averse to the mode and convenience of vaginal products' administration or to their use on account of potential systemic absorption, or those who demonstrate dissatisfaction in terms of efficacy and safety, it is clear that there is a significant unmet medical need in VVA management. In fact, a great number of women show lack of adherence, dropping out of at least one VVA treatment, including nonhormonal moisturizers and lubricants, which they consider to be ineffective and uncomfortable. If they could choose, many of them may opt for oral treatment. In Phase III studies, ospemifene demonstrated efficacy in vaginal dryness and dyspareunia, regenerating vaginal cells, improving lubrication, and reducing pain during sexual intercourse. Symptoms improved in the first 4 weeks and endured for up to 1 year. Additionally, it demonstrated a good endometrial, cardiovascular system, and breast safety profile.

Perceptions of dyspareunia in postmenopausal women with vulvar and vaginal atrophy: findings from the REVIVE survey

Symptoms of vulvar and vaginal atrophy (VVA), including dyspareunia and vaginal dryness, have a distinct negative impact on a woman's quality of life. The REVIVE survey highlighted the lack of awareness of VVA symptoms among postmenopausal women with vaginal symptoms, with many women reluctant to initiate discussions with their healthcare professionals despite the presence of vaginal symptoms. The REVIVE survey also provided insights into women's views of VVA treatments. Women reported displeasure with the vaginal administration route, lack of symptom relief with over-the-counter products, and concerns about the safety of estrogen therapies. With the high prevalence of VVA, obstetricians/gynecologists should become vigilant in identifying women with VVA by implementing screening and discussion of symptoms during routine office visits - providing patients with information about appropriate therapies based on the severity and impact of symptoms, keeping in mind individual preferences and perceptions.

Hyaluronic Acid: A Valid Therapeutic Option for Early Management of Genitourinary Syndrome of Menopause in Cancer Survivors?

Genitourinary syndrome of menopause (GSM) is a chronic condition affecting a large number of women, with a major impact on their urogenital health and sexual function. It occurs at midlife because estrogen levels decline with menopause enhancing aging-related changes of the functional anatomy of the urogenital system. Unfortunately, GSM may occur early in the lifespan of women or be exacerbated following anticancer treatments, such as chemotherapy, ionizing radiation, or surgical removal of reproductive organs. Symptoms of GSM are often under-reported by women, under-estimated and under-diagnosed by health care providers (HCPs), and subsequently under-treated, despite their profound negative impact on the quality of life. The mainstay of vaginal treatments is local estrogen therapy (LET) ensuring an effective management of moderate to severe symptomatic GSM. However, LET is generally contraindicated in women with a history of hormone receptor positive cancer, due to the fear of increased recurrence or possible interference with endocrine adjuvant therapies. Among non-hormonal treatments, hyaluronic acid-based moisturizers have shown promising clinical results both in healthy women and in cancer patients or survivors. Its strong water-binding properties provide lubricating and moisturizing effects, which contribute to maintaining a proper level of hydration and viscoelasticity in several body parts, including the urinary tract and genital tissues. Hyaluronic acid-based moisturizers are effective, safe, and well tolerated; therefore, they may represent a valid option for the early management of GSM-associated symptoms in every woman with a history of cancer who is unable or unwilling to undergo hormone-based therapies. Hence, the aim of this review was to provide an overview of GSM etiology and treatment in women with natural or iatrogenic menopause, with a focus on the use of hyaluronic acid as a prophylactic treatment in the context of an integrated management protocol for cancer patients.

Ospemifene for the treatment of dyspareunia associated with vulvar and vaginal atrophy: potential benefits in bone and breast

Ospemifene is a selective estrogen receptor modulator (SERM), or estrogen receptor agonist/antagonist, that was recently approved by the US Food and Drug Administration for the treatment of dyspareunia associated with vulvar and vaginal atrophy, a chronic condition that affects up to 60% of postmenopausal women. Ospemifene is the first and only nonestrogen compound approved for this indication. Compared with other approved SERMs, such as tamoxifen, toremifene, bazedoxifene, and raloxifene, the estrogen-like effects of ospemifene in the vaginal epithelium are unique. This review first discusses the rationale for developing ospemifene, including its mechanism of action, and then focuses on the clinical development of ospemifene for the treatment of dyspareunia associated with vulvar and vaginal atrophy. Included are discussions of the effects of ospemifene on the endometrium, serum lipids, coagulation markers, bone, and breast cancer. In conclusion, ospemifene is a SERM with a unique estrogen agonist/antagonist tissue profile that was recently approved in the US for the treatment of dyspareunia associated with vulvar and vaginal atrophy in postmenopausal women. Ospemifene warrants further clinical investigation for the treatment and prevention of osteoporosis and breast cancer.

Ospemifene for vulvar and vaginal atrophy: an overview

The menopause-related decline in estrogen levels leads to an array of genital, sexual, and urinary symptoms collectively known as genitourinary syndrome of menopause. The constellation of symptoms associated with vulvar and vaginal atrophy (VVA) can have a profoundly detrimental effect on a woman's sexual function, relationships, and quality of life. Ospemifene is a selective estrogen receptor modulator indicated for treatment of moderate-to-severe symptomatic VVA in postmenopausal women who are not candidates for local vaginal estrogen therapy or have contraindications for estrogen products. Ospemifene is administered orally, thus avoiding the inconveniences of local therapy, and can be used in women with VVA and a history of breast cancer after completing all (including adjuvant) breast cancer treatment. As well as restoring vaginal health in symptomatic VVA, ospemifene may have collateral benefits of importance to postmenopausal women. In this Special Issue entitled "Treatment of Vulvar and Vaginal Atrophy: Clinical Experience with Ospemifene," illustrative case studies examine the experiences of women with VVA during treatment with ospemifene. Specific topics include the effects of ospemifene on bone markers; its use in breast cancer survivors and in women with dyslipidemia, urinary incontinence, or VVA-related sexual dysfunction; and its concomitant use with laser therapy.

Symptoms, attitudes and treatment perceptions of vulvo-vaginal atrophy in UK postmenopausal women: Results from the REVIVE-EU study

OBJECTIVES

To describe the attitudes and perceptions of postmenopausal women from the United Kingdom regarding menopause, vulvo-vaginal atrophy and its therapeutic management.

STUDY DESIGN

Post hoc analysis of the United Kingdom population from the REVIVE-EU Study.

MAIN OUTCOME MEASURES

The survey contained questions about women's knowledge of menopause and vulvo-vaginal atrophy symptoms, impact on their life and sexual activities, communication with healthcare professionals and treatments.

RESULTS

The most frequent symptom of menopause was hot flushes (75%). Vulvo-vaginal atrophy symptoms had a significant impact on participants' ability to enjoy sexual intercourse (66%), spontaneity (62%) and ability to be intimate (61%); however, only 68% of women had been to their healthcare professional for advice. Half of the sample expected that doctors would initiate a discussion of menopausal symptoms and sexual health, but was in fact rare (5%). Only 27% were under current treatment without a clear therapy pattern, of which 43% used vaginal over-the-counter treatments, 28% prescription (Rx), and 13% both. Efficacy was the main limitation for over-the-counter treatments, while for Rx products were side effects and safety. Women highlighted the restoring of the natural condition of the vagina as the main goal for a treatment (35%). Many United Kingdom women did not feel the need to see any healthcare professional for their gynaecological symptoms. Overall satisfaction with treatment was only 44%.

CONCLUSIONS

Vulvo-vaginal atrophy remains underdiagnosed and undertreated in United Kingdom. There is a lack of coherent discussion about vulvo-vaginal atrophy symptoms with clinicians. Many United Kingdom healthcare professionals could improve proactive communication with patients about vulvo-vaginal atrophy.

Estradiol softgel inserts for the treatment of VVA symptoms: an expert opinion

INTRODUCTION

Vulvar and vaginal atrophy (VVA) affects up to two thirds of postmenopausal women, with symptoms of vaginal dryness, dyspareunia, and vulvar/vaginal irritation. Despite the availability of various treatments, women express dissatisfaction with their options. An estradiol (E2; 4-µg and 10-µg) softgel vaginal insert was approved by the Food and Drug Administration (FDA) to treat moderate to severe dyspareunia, a symptom of VVA, due to menopause. These inserts were designed to treat VVA effectively and safely while avoiding some of the drawbacks of other administration methods.

AREAS COVERED

This article reviews the physical characteristics and pharmacokinetic data of the E2 softgel vaginal insert. Primary and secondary efficacy endpoints and safety data are reviewed from the pivotal REJOICE trial (NCT02253173), and substudies that explore response rates, changes in vaginal epithelium by visual assessment, efficacy in patient subgroups, effects on sexual function, and patient satisfaction compared with other treatments.

EXPERT OPINION

The E2 insert shows that vaginal drug delivery is an optimal route of administration for locally treating VVA. This E2 softgel vaginal insert is a safe and effective treatment for symptoms of postmenopausal VVA. The E2 insert's pharmacokinetic characteristics are related to its unique formulation, rapid dissolution, and minimal systemic absorption.

ABBREVIATIONS

AE: adverse event; AUC: area under the concentration-time curve; BMI: body mass index; C_avg: average concentration; CI: confidence interval; C_max: maximum concentration; C_min: minimum concentration; E2: estradiol; FDA: Food and Drug Administration; FSFI: Female Sexual Function Index; GSM: genitourinary symptoms of menopause: MBS: most bothersome symptom; NAMS: North American Menopause Society; OR: odds ratio; PI: pulsatility index; PK: pharmacokinetic; REVIVE: Real Women's Views of treatment options for menopausal Vaginal changEs; RI: resistance index; ROC: receiver operating characteristic; TEAE: treatment-emergent adverse event; t_max: time to maximum concentration; VVA: vulvar and vaginal atrophy.

Ospemifene plus fractional CO2 laser: a powerful strategy to treat postmenopausal vulvar pain

This study is a single-center, retrospective analysis of postmenopausal women presenting with dyspareunia and vulvar pain, aiming to evaluate relative effectiveness of vestibular CO₂ laser therapy as a treatment. Three monthly sessions of laser were performed to each patient and thereafter a three-months follow-up was stablished. A total number of 72 patients undergoing vestibular laser treatment were recruited from patient files in the period between 2016 and 2018. Among these, 39 women also received a concomitant treatment with ospemifene (60 mg/day) during the study period. There was a statistically significant reduction of all the symptoms in both groups up to the three month follow-up. Regarding dryness and dyspareunia, the relief tent to be more prominent in the ospemifene + laser group at all follow-ups and remained statistically significant at three-month follow-up. Specifically, vestibular dryness was significantly lower in the ospemifene + laser group compared with the laser treatment group (-87% vs - 34%, respectively), and the vestibular health score started declining faster in the ospemifene + laser group. Although, additional research is needed to understand the mechanism of action, our data shows that a combination regimen of laser and ospemifene may improve clinical effectiveness for long-term treatment of symptoms associated with the under-recognized genitourinary syndrome of menopause.

Helping Women Understand Treatment Options for Vulvar and Vaginal Atrophy

Vulvar and vaginal atrophy (VVA) is a common and progressive medical condition in postmenopausal women. The REVIVE (REal Women's VIews of Treatment Options for Menopausal Vaginal ChangEs) survey assessed knowledge about VVA and its impact in 3,046 postmenopausal U.S. women, and recorded women's attitudes about their interactions with health care providers and about available treatments. REVIVE identified poor disease awareness and understanding among women, failure of health care professionals to evaluate women for VVA signs and symptoms, low treatment rates and concerns about the safety and efficacy of available therapies. Strategies to address these needs include proactive screening, education for women and clinicians about VVA and recommendations for treatment and follow-up.

Macro-regional variation in attitudes toward and experiences of vulvar and vaginal atrophy among Italian post-menopausal women: a post hoc analysis of REVIVE survey data

Italian participants in the European REVIVE survey reported that vaginal and vulvar atrophy (VVA) impaired various aspects of their lives, notably the ability to enjoy sex. The aim of the present study was to explore regional differences in knowledge, experiences, and treatment of VVA in the Italian REVIVE sample (n = 1000), which was analyzed according to region of residence. While many respondents were unfamiliar with the VVA condition, most could relate their VVA symptoms to the menopause. The rate of diagnosis of VVA was twice as high in Central Italy as in the North-East. For individual VVA symptoms, 25.4-41.6% of respondents judged that the symptom had worsened over time. There were no significant regional differences for symptoms in terms of reported rate, change in severity, impact on sexual activity, or health-care visits. Testosterone cream and OTC medication based on hyaluronic acid showed significant regional differences in lifetime rates of use. In Italy, there are modest regional differences in knowledge, diagnosis, and treatment of VVA, some of which may be explained by inter-regional differences in health care. Further efforts are needed to ensure that Italian women are properly informed about VVA and have access to appropriate health care and treatments.

Experience with ospemifene in patients with vulvovaginal atrophy treated with laser therapy: case studies

Vaginal laser therapy is a non-hormonal treatment option for vulvovaginal atrophy (VVA), a component of the genitourinary syndrome of menopause. Through a microablative and/or thermal effect on atrophic vaginal epithelium, laser therapy activates growth factors that increase vascularity and collagen production. Laser and ospemifene are complementary treatments: the laser’s effects on intra- and extracellular water are supported by the activity of ospemifene at estrogen receptors to restore vaginal epithelium and natural lubrication. This article reports the clinical course of two women with dyspareunia preventing sexual intercourse who were treated with ospemifene and laser therapy. The woman in case 1 had extreme vaginal stenosis and severe VVA symptoms. CO₂ laser therapy accompanied by estriol vaginal gel and vaginal moisturizer was unsuccessful. After ospemifene and three sessions of laser therapy, followed by vaginal ring resection and continued physiotherapy-directed mechanical dilation of the vagina, she was asymptomatic within 6 months. The woman in case 2 had severe VVA, which had prevented penetration for 2 years. Ospemifene was administered for 1 month to prepare the vaginal epithelium for photothermal therapy. A single erbium:YAG laser session and continued ospemifene treatment improved her symptoms sufficiently to allow her to resume sexual relations within 2 months.

Experience with ospemifene in patients with vulvar and vaginal atrophy and urinary incontinence: case studies

Pelvic floor muscle atrophy and collagen loss in connective tissue due to declining estrogen production in women as they age may underlie the increasing prevalence of urge and stress incontinence. Estrogen therapy can correct the deficiency of estrogen receptors in genitourinary structures after menopause, but estrogen is not suitable for all women. A series of retrospective studies showed that urinary symptoms improved in women with overactive bladder syndrome who were receiving ospemifene for vulvovaginal atrophy (VVA), a component of genitourinary syndrome of menopause. Two case studies presented in this article support the findings. The woman in case 1 was 76 years old, had a 4-year history of urinary incontinence (UI), and several risk factors for urinary symptoms. During 15 months' treatment with ospemifene for VVA, her urinary symptoms also improved as evidenced by a reduction (from four/day to one/day) in sanitary pad requirements to manage leakage. The patient in case 2 had predominantly moderate-to-severe VVA and mild mixed UI. During 6 months' treatment with ospemifene, she experienced marked improvement in VVA symptoms, including normalization of vaginal pH and disappearance of dyspareunia, accompanied by a decrease in urinary symptoms, which allowed her to resume a normal exercise program.

Experience with ospemifene in patients with vulvar and vaginal atrophy and associated sexual dysfunction: case studies

The pathophysiological changes associated with hypoestrogenism of menopause, a condition known as genitourinary syndrome of menopause, are responsible for the hallmark symptoms of vulvovaginal atrophy (VVA), namely dyspareunia secondary to vaginal dryness. Many postmenopausal women with VVA find sexual relations to be challenging or impossible. Ospemifene has estrogen-like effects on the vaginal epithelium, and is indicated to treat moderate-to-severe symptomatic VVA (Europe) or moderate-to-severe symptomatic dyspareunia and vaginal dryness (United States) in postmenopausal women. The case studies presented in this article follow the progress of two women who began treatment with ospemifene for the main presenting symptom of dyspareunia. Both women had concerns about the impact of their symptomatology on new relationships. The patient in case 1 experienced relevant improvement within 3 months of treatment start and, by 1 year, dyspareunia was absent. Vaginal lubricants were no longer required. The patient in case 2 experienced relevant improvement within 4 weeks of starting ospemifene. At 15 months, with the use of a lubricant for vaginal penetration, she could enjoy sexual intercourse without pain. At the time of writing, she had been receiving ospemifene continuously for more than 2 years with effective symptom relief and good tolerability.