Review of current and emerging estrogen receptor agonists for vaginal atrophy.

INTRODUCTION: Vulvovaginal atrophy (VVA) predominantly affects postmenopausal women due to hormonal decline but can also occur in premenopausal women with conditions such as primary ovarian insufficiency or exposure to anti-estrogen medications. Contributing factors include smoking and certain medical treatments. Symptoms like dyspareunia and loss of sexual function affect many women but are underreported due to stigma and lack of awareness. Current treatments range from over-the-counter lubricants to hormonal therapies like estrogen receptor agonists, which improve vaginal elasticity and moisture with minimal systemic absorption.

AREAS COVERED: This review evaluates current and emerging estrogen receptor agonists for VVA treatment. A comprehensive search was conducted using PubMed between August and September 2024, supplemented by snowball sampling from key references.

EXPERT OPINION: Despite its prevalence, VVA remains underdiagnosed, with increasing recognition due to longer lifespans and focus on quality of life. Diagnosis involves comprehensive symptom assessment, including sexual history, urinary tract infection frequency, and clinical exams, with vaginal pH measurements and smear microscopy to determine the condition's severity. Treatment usually involves estrogen, but not all women can safely use it, and preferences toward estrogen must be respected. Alternatives like selective estrogen receptor modulators (SERMs) such as prasterone and ospemifene show promise but need more long-term safety data. Emerging options like E3 and E4 demonstrate efficacy and safety in low doses. Future treatments will emphasize convenience and adherence, making timely diagnosis and management of VVA routine in women's health care.