A 55-year-old postmenopausal woman complains of complete sexual disinterest. We have taken care of her for many years. She had a fairly uneventful menopause, with some vasomotor symptoms (VMS); her last menstrual period was 4 years ago. The vasomotor symptoms are mostly resolved at this point. She has been married for 30 years; she has two children who have both graduated from college and are out of the house. She is a high school teacher in the neighboring town. Upon investigating her bother, she does note that once she starts participating in sexual activities (or as she states, “once she gets going”), she gets interested, but she could care less about “getting going in the first place.” She has recently heard about a new medication, which she has heard referred to as “the female Viagra,” and has also recently read an article on the promise of testosterone for sexual health in women. She is coming in to ask whether we thought that might help her situation. Her physical examination is unremarkable except for evidence of vulvovaginal atrophy (VVA), which is a significant change since her last exam a year prior. Her vagina now shows pallor and a loss of rugae. When we checked her vaginal pH, it is now 5.5.

Special considerations for our patient’s case as detailed above include a relatively isolated complaint of “lack of sexual interest” in an otherwise asymptomatic 55-year-old. Focal examination however identifies evidence of vulvovaginal atrophy. Potential mechanisms for her presenting symptom including differential diagnoses and management options including hormonal and nonhormonal strategies will be discussed, and thought process for the management approach for the case will be outlined.

Sexual dysfunctions are classically divided into several different categories. Technically, your patient would be categorized as suffering from hypoactive sexual desire disorder, which is the most common variety [1]. However, in postmenopausal women, symptoms of VVA, now officially referred to as the genitourinary syndrome of menopause (GSM), are a common contributory mechanism underlying varying degrees of sexual dysfunction [2].

The majority of postmenopausal women will develop VVA. In a recent survey of women with VVA, only 7 % reported that they were queried about their symptoms [3]. Your patient tells you that she is quite dry. You ask if she has used any over-the-counter remedies, and she mentions that she has used a lubricant. Most women do not appreciate the difference between long-acting moisturizers, which can offer lasting relief, and lubricants that offer only transient relief and are to be used at the time of intercourse. The use of vaginal moisturizers, particularly the polycarbophil-based formulations should be offered as first-line approach [2].

For patients who are experiencing bothersome VMS in addition to focal vaginal symptoms, systemic estrogen therapy will effectively address VMS and, based on estrogen dose, can help vaginal symptoms as well. For patients with minimal systemic symptoms whose bother relates to VVA, similar to the discussed case, management should focus on strategies offering vulvovaginal benefit [4].

Menopausal hormone therapy is effective to varying degrees, against the spectrum of symptoms commonly encountered during the menopause transition and in postmenopausal years. From the perspective of vaginal symptoms, a variety of prescription formulations (tablets, rings, and creams) of vaginal estrogens are available (Table 9.1). At the start of treatment, frequent dosing (even daily) of tablets/creams is recommended for the initial 2–3 weeks followed by maintenance dosing at twice weekly frequency; unlike the tablets and creams, the vaginal ring (Estring) is designed to be retained in place for 3 months at a time. Many women will benefit by both intravaginal therapy (ring, cream, or tablet) and topical application of estrogen cream externally to the vulva and the introitus. While subjective improvements are commonly seen sooner, objective evidence of improvement in VVA is usually seen within 1–2 months of treatment [2].

Also available currently is the first oral non-estrogen therapy for VVA. Ospemifene is an oral selective estrogen receptor modulator (SERM) that recently gained FDA approval for management of symptoms of VVA. It binds to the estrogen receptors in the vagina and effectively improves vaginal lubrication, epithelial integrity, and genitourinary symptoms of menopause [2]. Although there are no head-to-head comparator trials available, the magnitude of symptom benefit from ospemifene use is similar to that seen with the use of vaginal estrogens [5]. Ospemifene may be preferentially considered for women who are esthetically averse to vaginal inserts (creams, tablets, rings). Women who are anxious about the use of estrogens in any form may find ospemifene an acceptable alternative, an agent that is deemed a non-estrogenic formulation; it is however important to appreciate that the action of this class of agents is mediated through the estrogen receptors. Potential side effects related to ospemifene use include a slight chance of transient worsening of hot flashes and leg cramps, which usually resolve quickly. As with all SERMs, there is a slight increase in the risk of thromboembolism [6].

Although from a theoretical perspective, similar to other SERMs including tamoxifen and raloxifene, ospemifene should have a favorable breast profile, clinical data on this aspect are lacking, and ospemifene has not yet been evaluated in breast cancer survivors [7].

All hormonal products available to address symptoms of VVA carry the black box warning attendant with systemic estrogens (even though the systemic absorption of vaginal estrogens is minimal). The North American Menopause Society has been meeting with the FDA to remove these warnings; however, as menopausal hormones including vaginal formulations are still packaged with the warnings, it is appropriate to discuss these with patients before they receive them at the pharmacy [8].