vaginal dryness cim

A REAL NEED:Vaginal Moisturizers for

Urogenital Atrophy

Ma Virginia M Santos-Abalos MD FPOGS FPSGE

Professor, Cebu Institute of Medicine, CDU College of Medicine

Advisory Board / SpeakerAbbott Solvay

Bayer Philippines

Biofemme

Glaxo Smith Kline

MSD Philippines

Nycomed

Disclosure

FACTSThreats to normal vaginal health at any stage of a woman’s life

Altered Vaginal Health

1 Increased risk for infections (BV)

2 Likelihood of adverse pregnancy outcome

3 Poor quality of life in the peri- and menopausal years, and during chemotherapy for breast CA

4 Impaired sexual function

3 Poor quality of life in the peri- and menopausal years, and during chemotherapy for breast CA

4 Impaired sexual function

GENITOURINARY Tract

Embryologically and anatomically in close proximity

Presence of estrogen receptors in the mucosa

Pathophysiology in one produces symptoms in adjacent organ

Discussion Points

Burden of the disease

Estrogen and vaginal health

Practical management options for women presenting with ‘vaginal dryness’

Burden of the Disease

How common is vaginal dryness?

Does this cause significant suffering?

Vulvovaginal Atrophy can occur at any time in a woman’s life cycle

Hypoestrogenic state

Postmenopause

Lactation

Hypothalamic amenorrhea

Various breast cancer treatments

Drug-induced Certain medications e.g antihistamines

Postmenopause

Various breast cancer treatments

Prevalence of superficial dyspareuniaand vulvovaginal atrophy by menopausal age

Adapted from Versi E, et al. Int Urogynecol J 2001;12:107–10

Perimenopause(n = 133)

0–1 year(n = 52)

2–3 years(n = 39)

4 years(n = 67)

Atrophy increased significantly with increase in menopausal age (p <0 .001)

Vaginal dryness with menopause

Dennerstein L, et al. Obstet Gynecol 2000;96:351–8

Pre-menopause

(n = 172)

Earlyperimenopause

(n = 148)

Lateperimenopause

(n = 106)

Post-menopause

1 year(n = 72)

Post-menopause

2 years(n = 54)

Post-menopause

3 years(n = 31)

3%

47%

21%

25%

32%

4%

Dryness increased significantly in late perimenopause and postmenopause (p <0 .001)

Lower estrogen levels are associatedwith increased prevalence of sexual problems

0

10

20

30

40

50

60

Vaginal dryness

Bothered by problem

Dyspareunia (intensity)

Pain with penetration

Burning

% R

epo

rtin

g p

rob

lem

s

<184 pmol/l (50pg/ml) estradiol

>184 pmol/l (50pg/ml) estradiol

Sarrel PM. J Womens Health Gend Based Med 2000;9:S25–32

Adapted from Sarrel PM. Obstet Gynecol 1990;75(4 Suppl):26–30SSantiago Palacios. MATURITAS 63 (2009) 315-318

n = 93; significance not reported

VAGINAL ATROPHY: Symptoms Santiago Palacios. MATURITAS 63 (2009) 315-318

Vaginal dryness

Bothered by problem

DyspareuniaPain with

penetrationBurning

• Up to 40% of postmenopausal women experience vaginal atrophy

• Only 25% of them seek medical assistance

Prevalence of vaginal atrophy

Bachman GA, et al. Am Fam Physician 2000;61:3090–6Cardozo L, et al. Obstet Gynecol 1998;92:722–7

Estrogen Deficiency: SYMPTOMS

Short term

Menstrual irregularitiesVasomotor disturbancesHot flushes, sweats, palpitationsIrritability, mood swingsFatigue, depression

Medium term

Decreased libidoAtrophic vaginitisDyspareuniaUTI

Long term

Bone loss, osteoporotic fracturesCardiovascualr disease

Medium term

Decreased libidoAtrophic vaginitisDyspareuniaUTI

Unlike vasomotor symptoms, which typically resolve over time, vaginal atrophy remains a persistent consequence of the menopausal transition and frequently requires treatment

Vaginal Atrophy

International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010

Prevalence of symptoms inwomen treated for breast cancer

Symptom Symptoms (%)

Moderate – severe (%)

Hot flushes/sweats 85 63

Sexual problems 60 45

Urinary problems 55 39

Vaginal dryness 55 34

Gupta P, et al. Climacteric 2006;9:49–58

Menopause Rating Scale; n = 200

Vaginal dryness 55 34

Sexual problems 60 45

Estrogen & Vaginal Health

Vaginal Cell Maturation

MI = 10/30/60

S

MP

I

Superficial

Intermediate

Parabasal

Metaplastic

10% Parabasal

30% Intermediate

60% Superficial

Estrogen

Döderlein's lactobacilli convert glycogenfrom sloughed vaginal cells

Lactic acid

Glycogen formation

Vaginal pH (3.5-4.5)

Protects from:Streptococcus

StaphylococcusColiform

Diphtheroid infections

Mucus layer

Maintains thickness

of squamous vaginal epithelium, rugae,

pink color, and moisture

Proliferation of connective tissueFragmentation of elastinHyalanization of collagen

Effects of estrogen on the vaginal epithelium

IMS Writing Group. Recommendations for the management of postmenopausal

vaginal atrophy. Climacteric. 2010

WELL-ESTROGENIZED VAGINA

Layers well-delineatedNormal Introitus

Gross Changes with Estrogen Loss Mehta A, Bachmann G. Vulvovaginal complaints. Clin Obstet Gynecol. 2008;51:549-555

Loss of labial and vulvar fullness

Pallor of urethral & vaginal epithelium

Minimal vaginal moisture

Loss of urethral meatal turgor Atrophy Of Labia Majora

Low Moisture Content

Estrogen and Physical Changes

Vaginal Atrophy Normal vulvovagina

ESTROGEN and Histologic changes

WELL-ESTROGENIZED ESTROGEN LOSS

NORMAMulti-layered w/ good blood supply Superficial cells rich in glycogen

Atrophy with marked thinning of the epithelium Reduced blood supply Loss of glycogen

Vaginal histology

Premenopause

Well-estrogenized epithelium, multi-layered with good blood supply; superficial cells rich in glycogen

Postmenopause

Estrogen-deficiency atrophy with marked thinning of the epithelium, reduced blood supply and loss of glycogen

H & E, magnification 10

Postmenopausal changesin the vaginal epithelium

Loss of folds Folds or rugae

Muscular coat

Erectile tissue

Inner lining contains large

amount glycogen

Loss of inner lining and glandular function

PREMENOPAUSAL POSTMENOPAUSAL

Samsioe G. A profile of the Menopause, 1995:49 (Figure 6.4)

Clinical Assessment of the Vagina Adapted with permission from Parsons A, et al. Obstet

Gynecol. 2003

DEGREE MILD MODERATE SEVERE

RUGAE Reduced Rare Smooth vagina

PALLOR Light pink Pale White / deep red

PETECCHIAE Rare Bleeds on scraping

Bleeds on contact

MUCOSAL ELASTICITY Decreased None Stenosis

DRYNESSSlightly decreased

Minimal Dry

VAGINAL pH >4.5 <5 5 & > >5

HORMONE CHANGES

Diabetes Oral Contraceptive Pills Aromatase Inhibitors (AI)ANTI-MICROBIALS

MENSES

SEMEN pH= 8

SOAP pH= 7-10

THREATS to the vaginal ecosystem

ESTROGEN

GLYCOGEN

LACTOBACILLI

LACTIC ACID

pH 3.8-4.5

Correlates with decreased risk for RTIs (Chlamydia and Trichomonas), as well as UTI. (Bosket et al. Infect Immuno 1999)

Increases lactobacilli ability to bind to the vaginal epithelium Reduces the activity of pathogenic bacterial enzymes such as ‘sialidase’. (Nagy et al. BJOG 1985)

Protective against BV, mycoplasma hominis, bacteroides;maximum attachment of Gardnerella to vaginal cells at alkaline pH 5-6. (Cauci et al. AJOG) (Sobel JD. BV., Annu Rev Med 2000)

Vaginal pH, predictor of status of vaginal ecosysytemAcid vaginal pH a protective mechanism for RTI, UTI

Vaginal ph and Maturation Index

Surrogate markers of vaginal health

ALTERED VAGINAL HEALTH, A FACT OF LIFE FOR EVERY WOMAN AT SOME POINT

Estrogen Therapy

Lifestyle & Behavioral modification

Non-Hormonal therapy

Management Options

Estrogen and Vaginal Atrophy

Research has shown that low-dose vaginal estrogen is effective and well tolerated for treating vaginal atrophy and has been shown to reduce vaginal symptoms, including dyspareunia and vaginal dryness, and to restore vaginal pH and normal vaginal cytology

Estrogen therapy reverses atrophy

Huang, Kaley. Gender-specific regulation of CV function: Estrogen as key player. Microcirculation 2004; 11 (Jan-Feb (1): 9-38)

Johnston, Farrell, Bouchard, Beckerson, Comeau, Lefebvre, Papaioannou. SOGC Joint Com-CPG Gynecology and Urogynecology. Detection and Management of Urogenital Atrophy. J Obstet Gynec Canada 2004; 26 May (5): 503-15)

Suckling, Lethaby, Kennedy. Local Estrogen for vaginal atrophy in Postmenopausal Women. Cochrane Database 2006; 18 October

NAMS. The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopasusal women. 2007 Position Statement) Pitkin, Rees. British Menopause Society Council. Urogenital Atrophy.

Menopause Int 2008; 14 Sept (3) 136-7)

Menopausal women suffering from Atrophic Vaginitis

61%

39%

Women without systemic HRT

With atrophic vaginitis

Without atrophic vaginitis

27%

73%

Women with Systemic HRT

Notelovitz M et al. Obstetrics Gynecology. 2002

Many women using systemic HRT still suffer urogenital symptoms

Menopausal women sufferingfrom atrophic vaginitis

Over half of postmenopausal women will have urogenital discomfort associated with estrogen deficiency

Although many women use oral hormone replacement therapy, urogenital symptoms persist

Patients suffering from atrophic vaginitisPatients not suffering from atrophic vaginitis

73%61%

27%39%

Women with systemic HRT Women without systemic HRT

Notelovitz M, et al. Obstet Gynecol 2002;99:556–62

Physician‘s perspective:

Postmenopausal Vaginal AtrophyIMS recommendations Climacteric 2011SOGC Clinical Practice Guidelines. J Obstet Gynaecol Can 2004

Detection & diagnosis

Health-care providers should routinely assess postmenopausal women for the symptoms and signs of vaginal atrophy, a common condition that exerts significant negative effects on quality of life. (III-C)General

Treatment

1Should be started early and before irrevocable atrophic changes have occurred

2Needs to be continued to maintain the benefits

Postmenopausal Vaginal AtrophyIMS recommendations Climacteric 2011SOGC Clinical Practice Guidelines. J Obstet Gynaecol Can 2004 Estrogen Therapy

1All local estrogen preparations are effective and patient preference will usually determine the treatment used

2All currently available topical estrogens are absorbed, the extent depending on dose and formulation.

3Although systemic absorption of estrogen can occur with local preparations, there is insufficient data to recommend annual endometrial surveillance in asymptomatic women using local estrogens. (III-C)

4Additional progestogen is not indicated when appropriate low-dose, local estrogen is used although long-term data (>1 year) are lacking.

Postmenopausal Vaginal AtrophyIMS recommendations Climacteric 2011SOGC Clinical Practice Guidelines. J Obstet Gynaecol Can 2004

If Estrogen ineffective or undesired

Vaginal lubricants and moisturizers can relieve symptoms due to dryness

Gynecological hormone-responsive cancers

1 Few data on the use of vaginal estrogens sothey should be used with discretion

2 Use of local estrogen in women on tamoxifen or aromatase inhibitors needs careful counselling and discussion with the patient and the oncology team.

However, given the fear many women have of estrogens, there is a motivation to explore alternative therapies.

Vaginal Atrophy & Estrogens

Winneker RC. Progress and Prospects in Treating Postmenopausal Vaginal atrophy. Clinical Pharmacology & Therapeutics Volume 89 Number 1 January 2011

Behavioral Modification Advantage

Are there practical strategies to maintain vaginal moisture?

OPTIONS for maintaining Vaginal Moisture

Diet Tofu, phytoestrogen

Hydration

Key for maintaining moist mucous membranes of the body

Caffeine and alcohol have a diuretic (dehydrating) effect, that can be more pronounced in some women

Women in perimenopause and menopause may have more difficulty clearing the body of these substances, and overconsumption of either — particularly alcohol — can exacerbate vaginal dryness


Medications/Chemicals that may aggravate vaginal dryness

Regulate intake of medications for allergies eg. antihistamine not only dry up sinuses, but vaginal secretions as well.

Chemically-enhanced feminine products / douching: can cause vaginal dryness by disrupting the delicate natural chemical balance of the vagina


Natural Strategies

Kegel exercises help increase circulation to the pelvic area to keep vaginal tissue healthy and strong.

Regular sexual activity should be encouraged to protect against urogenital atrophy, presumably by increasing the blood flow to the pelvic organs. (II-2B)

Leiblum S, et al.Vaginal atrophy in the postmenopausal woman: the importance of sexual activity and hormones. JAMA 1983

SOGC Clinical Practice Guidelines. J Obstet Gynaecol Can 2004

Vaginal Atrophy in the Postmenopausal Woman

The Importance of Sexual Activity and Hormonesn= 52Sexually active: ≥3/moSexually inactive: <10/yr

Index of genital atrophy

Blood samples: estrone estradiol androstenedionetestosterone FSH, LH

Less vaginal atrophy was apparent in the sexually active women as opposed to the sexually inactive women

Women with less vaginal atrophy had significantly higher mean levels of androgens (androstenedione and testosterone) and gonadotropins (particularly LH).

Leiblum S, et al.JAMA 1983

Will non-hormonal therapy work?

http://aa.wrs.yahoo.com/_ylt=A0WTf22JNEVN3GkAmDq1Rwx.;_ylu=X3oDMTBxMDdvdXFmBHBvcwMyMQRzZWMDc3IEdnRpZANJMTIxXzcy/SIG=1k104j2qs/EXP=1296409865/**http:/ph.images.search.yahoo.com/images/view?back=http://ph.images.search.yahoo.com/search/images?_adv_prop=image&b=21&ni=20&va=menopausal+woman&xargs=0&pstart=1&fr=ush_mailc&w=349&h=469&imgurl=www.menopause-metamorphosis.com/pic_gallery-herzer.jpg&rurl=http://www.menopause-metamorphosis.com/An_Art_Gallery.htm&size=36k&name=pic+gallery+herz...&p=menopausal+woman&oid=ba4dbfcaf27e06ea&fr2=&no=21&tt=943&b=21&ni=20&sigr=11p45pvqg&sigi=11mf2sedp&sigb=13ssc507k&.crumb=YkpGQkhL5eB

Non-HORMONAL Therapy Modified from NAMS. Menopause Practice: A Clinician's Guide, 3rd edition. Cleveland, OH: The North American Menopause Society; 2007

Composition Therapeutic Relevance

Water-based vaginal lubricants

Use limited to ease penetration during intercourse

Vitamin E oil

Eases penetration during sexual intercourse and may relieve itching, irritation



Vaginal moisturizer

Replenish and maintain water content in the vagina to relieve irritation, itching, and burningNot limited to sexual exchange

Vaginal gel Acidifies vaginal pH, reduces minor vaginal irritations and odors; may be used after intercourse and/or uterine bleeding



Vaginal lubricants

1 Eases penetration during sexual intercourse

2 Water-based, water-soluble, and slightly acidic (pH balanced) preferred. Petroleum products not recommended.

3 This slight acidity inhibits the growth of harmful microorganisms, yeast.

No long term therapeutic effect

Vaginal Moisturizers

Vaginal moisturizers applied on a regular basis

have an efficacy equivalent to local hormone

replacement for the treatment of local urogenital

symptoms such as vaginal itching, irritation, and

dyspareunia, and should be offered to women

wishing to avoid use of hormone replacement

therapy. (I-A)

SOGC Clinical Practice Guidelines. J Obstet Gynaecol Can 2004

POLYCARBOPHIL – BISABOLOLLACTIC ACID VAGINAL MOISTURIZING GEL

Polycarbophil-Bisabolol Lactic Acid Vaginal gel

Poly carbophil

1 Bioadhesive polymer in gel form Draws water out of the cells into the vagina Prevents volatilization of amines Promotes restoration of lactobacilli and acidifies vaginal pH

2 A weak polyacid ph=2.8Its large molecule is neither absorbed nor immunogenic.

3 With its multiple carboxyl radicals, it adheres to the vaginal epithelial cells until they turn over (3-5 days) and buffers vaginal secretionsCells regain natural elasticity and moisturePromotes healing of tissues.


α-Bisabolol

1 A Levomenol, a natural monocyclic sesquiterpene ROH

2 Colorless viscous oil, the primary constituent of the essential oil from German chamomile

3 Almost insoluble in water and glycerin, well soluble in ethanol

4 Has skin healing properties.Known to have anti-irritant, anti-inflammatory and anti-microbial properties.


LACTIC Acid

Acidifies vaginal pHReduces minor vaginal irritations and odorsMay be used after intercourse and/or uterine bleeding

STUDIES on EFFICACY and SAFETY

Polycarbophil vs. local Estrogen in menopausal women (Nachtigall LE. Fertil Steril Jan 1994)

Study n= 30>1year postmenopause, not on HRT, cancer-free and experiencing vaginal discomfort or dyspareunia.

Randomized Polycarbophil gel 3x/week for 12weeks

CEE cream 2g vaginally daily for 12weeks

Parameters Pap smear, vaginal pH, MI index (baseline, week4, week8, week12)


Results 1 Both had statistically significant return of vaginal moisture and vaginal fluid and premenopause pH levels by week 4

2 Women remained free of vaginal infections for the duration of the study

3 Both have increased vaginal elasticity; Statistically significant in the estrogen group by week4

4 Vaginal atrophy reversed at week12 in estrogen group.


Conclusion Polycarbophil gel is safe and an effective alternative to estrogen vaginal cream in postmenopausal women with uncomfortable symptoms of vaginal dryness, exhibiting increases in vaginal elasticity with return to premenopausal pH state

Polycarbophil versus dienoestrol cream in the symptomatic treatment of vaginal atrophy in postmenopausal women.(Bygdeman M, Swahn ML. Maturitas 1996)

Study n= 39Polycarbophil gel 3x/week for 12weeksDienoestrol daily during the first 2 weeks and thereafter 3x a week

Randomized

Parameters Vaginal dryness index, itching, irritation, dyspareunia, pH and safety were evaluated every week the first month and every month thereafter.


Results 1 Both treatments had a significant increase on vaginal dryness index as soon as the first week of treatment. Hormonal compound was significantly better than the non-hormonal one

2 All symptoms such as itching, irritation and dyspareunia significantly decreased or disappeared without any difference between the two treatments


Conclusion

Polycarbophil applied vaginally 3x a week, is a full therapy for all symptoms of vaginal atrophy as well as local estrogen. No serious adverse event was related.It is an alternative treatment to local estrogen and perhaps a good complement of systemic HRT in patient suffering from vaginal dryness.

Effect on Vaginal pH of a polycarbophil vaginal gel compared with acidic douche in women with suspected BV (Massimo M, Bruno M, Ilaria S. Current Therapeutic Research, Oct 2000)

Objective To compare and assess the pH-lowering effect of polycarbophil with acidic vaginal douche

Controlled, Randomized Blinded study

n=30 (18-60 yo), vaginal pH>4.5 & suspected BV (+ whiff test; + clue cells, gram stain score ≥4)

Groups 6 weeks:Polycarbophil gel 2.5gAcidic vaginal douche 2x a week


Outcomes Measured by investigator

Baseline, 3 wks, 6 wks

Vaginal pH, wet mount, KOH, Gram stain

Specimen obtained 8hrs after gel / douche use; day7 from LMP; 48hrs post-coital


polycarbophil

acidic douche


Results

Vaginal pH

Polycarbophil Acidic Douche

Week 3 4.7 (+/- 0.6) 5.4 +/- 0.5

Week 6 4.6 (+/- 0.7) pH 5.3 +/- 0.8

pH lowering effect of polycarbophil after single application is maintained up to 80 hrs

Effect on BV

Physical & microbiological signs of BV improved in the polycarbophil group

Adverse effects

No adverse effects noted in both groups


Conclusions

Polycarbophil vaginal gel reduces vaginal pH to almost physiologic levels and reduces vaginal pH in women suspected of BV, compared with acidic vaginal douche.

Polycarbophil may thus represent not only a way to reduce vaginal acidity and help maintain physiologic levels but may play an important role in preventing complications related to altered vaginal pH.

GYNECOLOGIC MANAGEMENT OF SEXUAL PAIN FROM ATROPHIC VAGINITIS AND VAGINAL ATROPHYCurr Oncology 2007 December; C. Derzko, MD,* S. Elliott, MD,† and W. Lam, BSc(Pharm) MD‡

In view of recent findings raising concerns over elevated circulating estradiol levels (from 0-5pmol/l to 72pmol/l) in breast cancer patients on AI therapy who are using transvaginal estrogenic preparations,

GYNECOLOGIC MANAGEMENT OF SEXUAL PAIN FROM ATROPHIC VAGINITIS AND VAGINAL ATROPHYCurr Oncology 2007 December; C. Derzko, MD,* S. Elliott, MD,† and W. Lam, BSc(Pharm) MD‡

In view of recent findings raising concerns over elevated circulating estradiol levels in breast cancer patients on AI therapy who are using transvaginal estrogenic preparations, non-hormonal therapies including regular application of vaginal moisturizers and lubricants are recommended and certainly be first-line therapy. In addition, pelvic therapy for pelvic tone awareness and pelvic floor exercises (eg, Kegel exercises) and lifestyle modification are preferred and should be considered early.

Practical Clinical Guidelines for Assessing and Managing Sexual Dysfunction and Atrophic Vaginitis after Breast CAM. Hickey; C. Saunders; A. Partridge; N. Santoro; H. Joffe; V. Stearns. Annals of Oncology Oct 2008 19(10):1669-1680

Vaginal estradiol may reverse efficacy of aromatase inhibitors in suppressing estrogen.

Estriol-containing preparations may be helpful, however, safety is still not established.

When vaginal dryness is contributory, non-hormonal agents such as vaginal moisturizers (polycarbophil-containing) may be effective for hypoactive sexual desire in these women.

Testosterone therapy is offered by some clinicians but it’s safety and efficacy have not been well-established.

MANAGING UROGENITAL ATROPHY: A Review Palacios S. Maturitas 63 (2009) 315-18

MANAGING UROGENITAL ATROPHYPalacios S. Maturitas 63 (2009) 315-18

The review provides a practical guide on the diagnosis and management of UGA.

A literature search done in MEDLINE (1969-2008) for original reports, meta-analysis and guidelines.

15% of premenopausal women and 40-57% of postmenopausal women have symptoms related to UGA. However, <25% receive medical care.


cont’d . . . . .

Lubricants are temporary measures to relieve vaginal dryness during intercourse, and moisturizers give longer symptomatic relief and has an effect on the vaginal epithelium maturity.

Estrogen given systemically in all dosage regimens is effective, but topical therapy alone is preferred if systemic treatment is not needed.

Treatment may be for long term as symptoms return when treatment is stopped.


ESTROGEN THERAPY 2006 Cochrane systematic review of 19 good quality

trials (4162 postmenopausal women randomized to different estrogen preparations for 3-6 months, and endpoints were efficacy, safety, acceptability; vaginal estradiol tablets more effective than the ring and clearly superior over placebo for symptom-relief).

Meta-analysis by Cardozo et al showed superiority of estrogen over placebo, and that the vaginal route is linked to a better outcome in UGA.

Conjugated estrogen cream, an intravaginal sustained-release estradiol ring, or estradiol vaginal tablets are recommended as effective treatment for vaginal atrophy. (IA)

Routine progestin cotherapy is not required for endometrial protection in women receiving vaginal estrogen therapy in appropriate dose. (IIIC)

Vaginal lubricants, moisturizers may be recommended for subjective symptom improvement of dyspareunia. (IIIC)

Health care providers can offer polycarbophil gel (a vaginal moisturizer) as an effective treatment for symptoms of vaginal atrophy, including dryness and dyspareunia. (IA)

Johnston S. Urogenital concerns. In: Canadian consensus conference on menopause. J Obstet Gynaecol Can

Urogenital Health Update 2009

SUMMARY

Threats to normal vaginal health at any stage of a woman’s life

Vaginal dryness associated with altered vaginal health is a concern but only a few seek medical care

SUMMARY

Polycarbophil-containing vaginal moisturizers reduce vaginal ph and improves moisture content and is effective for relief of vaginal dryness.

Initial studies of polycarbophil on maintaining acid vaginal ph and low IL-6 in low risk pregnant women seem promising and may be linked in the reduction of adverse pregnancy outcome.

Polycarbophil vaginal gel can be offered for managing vaginal dryness in breast CA patients.

VAGINAL DRYNESS, an emerging concern . . . . .

POLYCARBOPHIL-α BISABOLOL – LACTIC Acid containing vaginal gel, with its vaginal moisture elasticity, and pH- restoring properties, is a rational option.

VAGINAL MOISTURIZERS:

A REAL NEED

vaginal dryness cim

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