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Clinical Reviews

A guide to lotions and potions for treating vaginal atrophy

Options for relieving the related itching, dryness, burning, and dyspareunia include a variety of hormonal formulations and nonhormonal alternatives

December 2009 · Vol. 21, No. 12


The authors report no financial relationships relevant to this article.

The authors would like to acknowledge Lauren Melcher, MD, an ObGyn resident at Washington Hospital Center, who contributed to this article.

CASE: New-onset dyspareunia in a menopausal patient

J. B., 53 years old, has been menopausal for 2 years. Several months after her annual examination, she schedules another appointment to discuss a worsening complaint: dyspareunia. She says she never had the problem until she reached menopause, and reports that it has become so severe that she has started avoiding sexual intercourse altogether. Even when she avoids intercourse, however, she is bothered by vaginal itching and burning.

What can you offer to her?

Various hormonal and nonhormonal products are available to relieve the frequent complaint, in menopausal women, of symptoms of vaginal atrophy: vaginal dryness, itching, burning, and dyspareunia.1-3 The array of products isn’t really surprising: As women advance through menopause, their complaints of vaginal dryness increase fivefold.4

Systemic and local estrogen therapies reverse some atrophic changes and alleviate symptoms.5 After menopause, local vaginal estrogen formulations are recommended as first-line treatment for women who experience moderate or severe symptoms of vaginal atrophy.3 Formulations such as the vaginal ring, vaginal tablet, and transdermal gels and sprays are increasingly popular.

In this article, we describe these and other products, including nonhormonal lubricants and moisturizers, to relieve:

  • the range of symptoms of vaginal atrophy in menopausal women
  • isolated vaginal dryness in premenopausal women.

Although it is difficult to review all over-the-counter lubricant products on the market today, it is important for the practicing gynecologist to understand the basic categories and composition of the products to better counsel patients.

Is hormonal therapy always necessary?

When a postmenopausal woman complains of chronic vaginal dryness, and the exam is consistent with vaginal atrophy, the recommended treatment is local vaginal estrogen. If she complains of vaginal dryness during sexual intercourse only, a vaginal lubricant is a suitable option.

When a premenopausal woman complains of vaginal dryness, a vaginal moisturizer is the best long-term treatment option. However, a vaginal lubricant is recommended for intermittent dryness during intercourse or dyspareunia.

Local estrogens avoid many risks of systemic therapy

Topical estrogen preparations are available as vaginal creams, tablets, and rings, and as transdermal lotions, gels, and patches (TABLE 1). Local preparations are preferred to systemic therapy for the treatment of atrophy because they bypass the gastrointestinal tract, undergo less conversion in the liver, and improve local tissue with minimal elevation of the serum estradiol level.1,3

The vaginal ring (Estring) delivers the lowest systemic estradiol level—approximately 5 to 10 μg of estradiol daily. Femring delivers more estradiol daily and requires the addition of progesterone in women who have an intact uterus.

Studies suggest that patients favor the estradiol-releasing vaginal ring because of its ease of use, comfort, and effectiveness, compared with vaginal estrogen cream.2,5

Local estrogen formulations were compared and reviewed in a systematic Cochrane meta-analysis of 19 trials that included 4,162 women.5 Vaginal cream, tablets, and rings were all equally effective in treating symptoms of atrophy. One trial found that cream (conjugated equine estrogen) increased the risk of uterine bleeding, breast pain, and perineal pain, compared with vaginal tablets.

Newer estrogen formulations include topical and transdermal patches, gels, lotions, and sprays (TABLE 1), all of which are systemic. They are effective in the treatment of vasomotor symptoms and vaginal atrophy.


Topical estrogen formulations—a rundown of local and systemic options




Source of active ingredient

Absorbed locally



25 μg of estradiol

One tablet intravaginally daily for 2 weeks; then, twice weekly

Synthesized from soy



0.5 g (0.625 mg/g of conjugated estrogen)

Insert 0.5 g daily for 3 weeks; then, twice weekly (Note: Dosage can be increased to 2 g daily but this may require progesterone supplementation)

Urine of pregnant mares


0.1 mg of estradiol/g of cream

Insert 0.5 g daily for 1 or 2 weeks; then, twice weekly

Synthesized from soy and yams



2 mg (delivers 6–9 μg of estradiol daily)

Insert 1 ring intravaginally for 3 months

Synthesized from Mexican yams

Absorbed systemically



Delivers 0.05 mg–0.1 mg of estradiol daily

Insert 1 ring intravaginally for 3 months

Synthesized from soy



Delivers 0.05 mg or 0.1 mg of estradiol daily

Apply patch twice weekly

Synthesized from Mexican yams

Estradiol (generic)

Delivers 0.05 mg or 0.1 mg of estradiol daily



Delivers 0.025 mg, 0.0375 mg, 0.05 mg, 0.075 mg, or 0.1 mg of estradiol daily

Vivelle, Vivelle-Dot

Delivers 0.025 mg, 0.0375 mg, 0.05 mg, 0.075 mg, or 0.1 mg of estradiol daily

Synthesized from Mexican yams


Delivers 0.025 mg, 0.0375 mg, 0.05 mg, 0.06 mg, 0.075 mg, or 0.1 mg of estradiol daily

Synthesized from soy


Delivers 0.025 mg, 0.05 mg, 0.075 mg, or 0.1 mg of estradiol daily



Delivers 0.014 mg of estradiol daily

Apply patch once weekly (Note: Indicated only for prevention of osteoporosis)



Delivers 0.05 mg or 0.14 mg daily of estradiol plus 0.05 mg or 0.25 mg daily of norethindrone

Apply patch twice weekly

Synthesized from soy (estradiol) and Mexican yams (norethrindrone)


Estrasorb (lotion)

Content of two pouches delivers 0.05 mg daily of estradiol

Apply one packet to each leg daily

Synthesized from soy

EstroGel (gel)

1.25 g (0.75 mg of estradiol)

Apply one pump to arm once daily


Divigel (gel)

0.25 g, 0.5 g, or 1 g of 0.1% estradiol

Apply one packet to upper thigh daily

Elestrin (gel)

0.87 g (0.52 mg of estradiol)

Apply one pump to arm once daily



1.53 mg of estradiol in each spray

Apply 1-3 sprays to forearm daily


Source: Cirigliano M. Bioidentical hormone therapy: a review of the evidence. J Womens Health (Larchmt). 2007;16:600–631.

When to add a progestin

A progestin is recommended in addition to a systemic estrogen formulation in women who have a uterus. For low-dose, local vaginal estrogen formulations, a progestin is usually not needed.3 However, when the treatment is vaginal cream, consider progestin supplementation when the dosage exceeds 0.5 g twice weekly for an extended time (>1 year).

The serum estrogen level with local vaginal treatment is dose-dependent, and the long-term endometrial effects of vaginal estrogens are unknown. If vaginal bleeding develops, a workup is indicated and may necessitate imaging of the endometrial echo or endometrial sampling to rule out hyperplasia, neoplasia, and cancer.

Counsel the patient about any risks

If you prescribe transdermal or oral estrogen for a patient, be sure to counsel her about the risks of systemic therapy described in the Women’s Health Initiative.6

Consider the patient’s preference

Local estrogen treatment is recommended over systemic therapy for vaginal atrophy, but patient preference should also be considered. Some women may prefer the ring or tablet to minimize excess vaginal discharge, while others may prefer a cream because of its soothing effects. Always individualize management!

Lubricants and moisturizers

Insufficient lubrication during intercourse is a common complaint among both premenopausal and postmenopausal women: As many as 60% of women report intermittent episodes of insufficient lubrication.7

Many women and their partners use a vaginal lubricant to assist with sexual relations and to self-treat for pain. A wide variety of nonhormonal products are available—many of them advertised at pharmacies and in the media—despite little published scientific evaluation. Because gynecologists routinely counsel patients on sensitive matters, including sexual practices, you may find it valuable—with appropriate candidates—to open a line of questioning about difficulties with intercourse and resulting attempts to self-medicate using over-the-counter products.

What are the indications?

A vaginal lubricant is a solution used locally, and as a temporary measure, to moisten the vaginal epithelium to facilitate a medical examination or sexual intercourse.2 Because it has a short duration, it must be applied at the time of intercourse. Lubricants can be categorized as water-, silicone-, and oil-based. Each formulation may affect the local inflammatory response, viability of sperm, and condom integrity.

A vaginal moisturizer is a gel or cream used regularly to maintain hydration of the vaginal epithelium for long-term relief of vaginal dryness.2

Both lubricants and moisturizers have many indications for both medical and personal use. Personal lubricants can be used for assistance during sexual activity, such as intercourse, masturbation, or use of sex toys. These products reduce friction and are thought to enhance pleasure in women who suffer from vaginal dryness. However, we lack sufficient data to confirm that lubricants can improve sexual dysfunction and vaginal atrophy. In general, these products are affordable, readily available, and may be helpful in the treatment of sexual dysfunction and vaginal dryness.

See TABLE 2 for a list of personal lubricants and vaginal moisturizers.


Vaginal moisturizers and lubricants are plentiful and diverse

Product (Manufacturer)




(Columbia Laboratories)

Water, carbomer, polycarbophil, paraffin, hydrogenated palm oil, glyceride, sorbic acid, and sodium hydroxide

Should be used 3 times weekly

Moist Again
(Lake Consumer Products)

Water, carbomer, aloe, citric acid, chlorhexidine deglutinate, sodium benzoate, potassium sorbate, diazolidinyl urea, and sorbic acid

Safe to use with a latex condom; no data on effects on sperm motility

Vagisil Feminine Moisturizer (Combe)

Water, glycerin, propylene glycol, poloxamer 407, methylparaben, polyquaternium-32, propylparaben, chamomile, and aloe


(Parnell Pharmaceuticals)

Water, mineral oil, glycerin, yerba santa, cetyl alcohol, and methyl paraben

Yerba santa (Eriodictyon spp), a plant native to the Pacific Northwest, is used as a moisturizer in place of aloe

K-Y Long Lasting Moisturizer

Purified water, glycerin, mineral oil, calcium/sodium PVM/MA copolymer, PVM/MA decadiene crosspolymer, hydrogenated palm glyceride, methylparaben, benzoic acid, tocopherol acetate, and sodium hydroxide


K-Y Silk-E

Water, propylene glycol, sorbitol, polysorbate 60, hydroxyethylcellulose, benzoic acid, methylparaben, tocopherol, and aloe



Slippery Stuff

Water, polyoxyethylene, methylparaben, propylene glycol, isopropynol



Water, glycerin, methylparaben, propylparaben, polypropylene glycol, polyquaternium, hydroxyethylcellulose, and sodium benzoate

Also sold in a glycerin-free and paraben-free formulation

K-Y Jelly

Water, glycerin, hydroxyethylcellulose, parabens, and chlorhexidine


Summer’s Eve Lubricant
(C.B. Fleet)

Water, propylene glycol, methylcellulose, xanthan gum, sodium lactate, methylparaben, lactic acid, dextrose, sodium chloride, edatate disodium, pectin, and propylparaben

FemGlide (WalMed)

Water, polyoxyethylene, methylparaben, and sodium carbomer

Pre-Seed (INGfertility)

Water, hydroxyethylcellulose, arabinogalactan, paraben, and Pluronic copolymers

Promoted to women and their partners who are trying to conceive


ID Millennium
(Westridge Laboratories)

Cyclomethicone, dimethicone, and dimethiconol

Less drying than other lubricants


Cyclopentasiloxane, dimethicone, and dimethiconol

Compatible with a condom


Dimethicone, vitamin E, aloe vera, dimethiconol, and cyclomethicone

K-Y Liquibeads

Dimethicone, gelatin, glycerin, and dimethiconol

Active ingredients are contained in so-called ovules that release lubricant over several days


Élégance Women’s Lubricant

Natural oils

Does not contain alcohol, glycerin, or parabens; is incompatible with a condom; helpful for women who have vulvodynia or vestibulitis

What to offer when estrogen is not an option

Some women may want to avoid hormonal treatment, or have a contraindication to it, such as estrogen-receptor–positive breast cancer.8 In premenopausal women, vaginal atrophy can occur with lactation or postpartum hormonal changes, or may result from the use of anti-estrogenic agents for breast cancer. Other candidates for nonhormonal therapy are women who have chronic vulvar pain syndromes. In these women, vaginal lubricants can be especially useful.

Although they are less effective than estrogen, vaginal moisturizers, such as Replens, have been shown to reverse symptoms of vaginal atrophy and decrease discomfort during intercourse.9

In the pipeline: A new SERM just for vaginal atrophy

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