Sexual function after menopause: the role of vaginal estrogens

Sexual health and well-being are challenged by the biopsychosocial changes associated with menopause. Local estrogen therapy (LET) represents the mainstay of managing genitourinary syndrome of menopause (GSM). However, most studies have investigated the role of LET on signs and symptoms of vulvovaginal atrophy (VVA) without fully capturing the sexual cluster of symptoms that makes women vulnerable to sexual dysfunction. The present review summarizes studies that have reported the impact of LET on sexual function and its domains (desire, arousal, lubrication, orgasm, pain, and satisfaction). Different formulations (tablet, soft gel inserts, vaginal ring, cream and gel) of estradiol and conjugated equine estrogens at low or ultra-low doses have been investigated. Most evidence supports a positive effect of LET on dyspareunia, while there is less information on the overall sexual experience in healthy postmenopausal women and in those with breast cancer. Importantly, LET has been considered as a class of drugs, with few studies addressing effects of different products on specific symptoms of the GSM constellation to provide evidence for a tailored treatment choice. It appears that GSM management at menopause is a priority to maintain sexual longevity. LET is part of the multifaceted approach to address women's needs and expectations. An evidence-based standard of care is warranted for the use of LET in the management of sexual dysfunction associated with menopause.