(117) Postpartum Vulvovaginal Dryness: Disparities in Adequate Treatment for Postpartum Patients’ Sexual Health
Authors: Bullen T , Rutkowski A , Branon L , Jun S Y , Rubin R 
Published: May 2023

Abstract

Introduction
Vaginal estrogen therapy (VET) use and efficacy is well established for genitourinary symptoms commonly seen in menopause. Despite the similar symptom profile and dramatic hormonal shifts in postpartum (PP) patients, they are not routinely offered the same therapies. The pathophysiology of these symptoms PP is multifactorial and frequently dismissed as “normal,” even with the subsequent negative effect on their quality of life. Concerns regarding potential harm on lactation and infant development further decreases utilization. However, these apprehensions may be outdated due to evolution of VET, warranting review of available literature.

Objective
To review the efficacy, concerns, and barriers of utilization of VET for vulvovaginal symptoms in PP patients.

Methods
A systematic review in the PubMed database spanning from January 1990 – June 2022 was performed to assess the relevant medical literature on the utilization of VET for vulvovaginal symptoms in PP patients. MeSH terms used to narrow the search include: [“dyspareunia” OR “vulvovaginal atrophy” OR “genitourinary”] AND [“hypoestrogenic state” OR “estrogenic endocrine disrupting compounds” OR “estrogen responsive tissues”] AND [“postpartum” OR “menopausal” OR “infant”] AND [“estrogen preparations” OR “vaginal estrogen”].

Results
The published literature (n=33) was analyzed by relevant key terms. FDA has approved a number of estrogen-based formulations for vulvovaginal atrophy and dysparenuia in menopausal patients, including: 7.5ug/day (vaginal ring), ultra low dose 10ug (vaginal tablet), 0.01% estradiol creams, premarin (conjugated estrogen) cream, and vaginal DHEA. Data for PP patients is limited with varying results. Nonetheless, drastic improvement in tissue thickening, lubrication, and baseline elasticity within a few weeks of minimal applied dosage of VET has been shown. Addressing primary worries, while higher doses (&gt;50mcg) of estrogen in the early PP period may negatively affect lactation, initiating VET after supply is well established (at 6-8 weeks) or using lower dose estrogen (≤50mcg) has no changes in lactation. In fact, the ultra-low-dose combined oral contraceptive pill (20mcg of ethinyl estradiol with progestins) is approved PP for contraception after 30 days with no adverse impact on breastfeeding. VET concentrations are smaller, and locally applied, implying even less risk of systemic effects. Tolerability is further enhanced with a personalized approach, prescribing the smallest effective dose for the shortest duration of time. Additionally, data suggests that if lactation is affected, there is no significant alteration to the infant’s growth, no to minimal increase of estradiol or estriol in breastfed infants, nor significant evidence of long-term prolongation of physiologic estrogenization. PP patients face numerous barriers, further limiting access to effective treatment, such as: varied clinical presentations, relatively high cost of therapies, minimal time and access to providers resulting in poor communication and hesitation, and limited research focused on therapeutic options for health concerns.

Conclusions
This review outlines the proven therapeutic uses, indications, and safety of VET, along with the scarcity of current literature for the PP population. The concurrent sexual dysfunction and discomfort can be devastating, supporting the need for focused research on the efficacy of VET connected to the specific needs and concerns of PP patients.

Disclosure
No