Treatment of vulvar pain caused by atrophy: a systematic review of clinical studies
Authors: Sánchez Sonia , Baquedano Laura , Mendoza Nicolás 
Published: August 2021

Background: The signs and symptoms of the genitourinary syndrome of menopause are well established, and there is extensive knowledge with high scientific evidence about the response that vaginal and urinary tissues present to various treatments. However, this does not usually apply to the vulva in general, or any of its structures in particular, since it is included in the term vulvovaginal. The aim of this review is to improve knowledge about the vulva and to improve symptoms in women who experience vulvar pain associated with atrophy. Methods: The study was registered at PROSPERO (registration number CRD42020172102). We also assessed the quality of evidence for each outcome of interest according to the GRADE criteria. Results: We systematically reviewed eight studies: four with ospemifene, a pilot study with prasterone, a study using a combination of estrogens and androgens, another study that used CO2 laser surgery and another with application of 0.005% estriol gel to the vulvar vestibule. Meta-analysis was not possible due to the heterogeneity and small sample size of the included studies. Ospemifene orally, at a dose of 60 mg daily for a time period of between 60 days and 20 weeks, report preliminary data showing improvements of vulvar and vestibule trophism. Prasterone showed in an open-label prospective survey, improve in the vulvoscopic results and dyspareunia, in women that used vaginal prasterone. The combination of estriol and testosterone propionate 2% for 12 weeks showed an improve of Vulvar pain due to atrophy (VPA) and dyspareunia in a descriptive prospective survey. A retrospective analysis of 79 postmenopausal women presenting vulvar pain who were treated with CO2 laser or laser plus ospemifene, showed that vestibular dryness was significantly lower in the ospemifene + laser group compared with the laser treatment group (–87% vs –34%, respectively). Finally, we also included a prospective open-label survey using for a 12-week treatment period, a fingertip to apply 0.25 g of vaginal gel containing 25 μg of estriol to the vulvar vestibule daily for three weeks and then twice weekly for up to 12 weeks. Dyspareunia improved or was cured (score ≤1) by week 12 in 81.4% of patients. Discussion: All the therapeutic strategies show improvement in vulvar pain, but not all are papers with the same scientific evidence. The best quality studies are those carried out with ospemifene since they are randomized and placebo controlled studies. However, the improvement demonstrated by prasterone, estriol, the combination of estrogens and androgens, as well as the CO2 laser, although they do not have high-quality studies, should not be ruled out since they promise good results and the user profiles they represent, allow more women to be reached. We propose a therapeutic strategy where the patient expresses her preferences, based on previous experiences and treatments already carried out. In addition, we believe that correctly informing patients about VPA can help a better therapeutic response. More investigation about the vulvar treatments is needed.