Oral Treatment Options for Genitourinary Syndrome of Menopause
Genitourinary syndrome of menopause (GSM) symptoms that are not relieved with over-the-counter therapies can be treated with low-dose vaginal estrogen or vaginal DHEA or oral ospemifene in women without indications for systemic hormone therapy. [1] Systemic hormone therapy can be used for GSM in appropriate candidates. [2]
Medication Selection Algorithm
- Oral ospemifene is selected for moderate to severe GSM symptoms when an oral prescription option is desired. [1]
- Systemic estrogen therapy is selected for women who also meet indications for systemic menopausal hormone therapy (including when GSM is part of the clinical presentation). [2]
- Vaginal therapies are preferred over oral routes for GSM because of a more favorable local-to-systemic exposure profile for many patients. [1]
Key Evidence Supporting Oral Options
- Oral ospemifene and low-dose vaginal estrogen or vaginal DHEA are effective treatments for moderate to severe GSM. [1]
Monotherapy Versus Combination Therapy
- When low-dose vaginal estrogen or vaginal DHEA or ospemifene is administered, a progestogen is not indicated. [1]
- Systemic hormone therapy should be prescribed based on systemic indication status and standard endometrial management principles for systemic regimens. [2]
Important Clarifications and Nuances
- Long-term endometrial safety data are limited for vaginal estrogen, vaginal DHEA, and ospemifene. [1]
- Safety data are insufficient to confirm GSM therapy safety in women with breast cancer for vaginal estrogen, vaginal DHEA, and ospemifene. [1]
Initiation Thresholds or Indications
- Prescription therapies are considered when GSM symptoms are bothersome and not relieved with over-the-counter therapies, particularly in women without indications for systemic hormone therapy. [1]
- Systemic hormone therapy is considered when GSM occurs in the context of an accepted systemic indication and the benefit–risk profile is favorable. [2]
Common Pitfalls to Avoid
- Use of endometrial-protection strategies that are unnecessary for ospemifene or vaginal estrogen/vaginal DHEA should be avoided because a progestogen is not indicated with these local therapies. [1]
- Assumptions of established long-term endometrial safety for ospemifene or vaginal DHEA/vaginal estrogen should be avoided because long-term data are lacking. [1]
Targets or Goals of Therapy
- Therapy goals include resolution of distressing GSM symptoms and improvement in sexual health and quality of life. [1]
- Symptom response should guide ongoing therapy selection when multiple GSM treatment options are available. [1]