Escogencia de la TE vaginal

Casi todos los productos de TE/TEP sistémicos y vaginales están aprobados para el tratamiento de los síntomas moderados y severos de la atrofia vaginal y vulvar, tales como sequedad vaginal, dispareunia y vaginosis atrófica. Cuando la TH es considerada solamente para esta indicación, la terapia local vaginal de TE (y no sistémica) está indicada. Debido a la evidencia de la similar eficacia entre los productos de bajas dosis locales vaginales de TE, la escogencia de cuál TE vaginal usar puede estar basada en la preferencia del paciente81.

Necesidad de progestágeno

La NAMS en su declaración de posición del 2007 se pronunció acerca de que el uso de estrógenos y progestágenos en las mujeres perimenopáusicas y posmenopáusicas81 indica que los progestágenos en general no están indicados cuando se administran dosis bajas de estrógenos localmente para la atrofia vaginal. En la revisión de Cochrane34, los autores concluyen que los datos disponibles no pueden contestar la pregunta de si las mujeres necesitan progestágenos para contrarrestar los efectos adversos de la posible absorción vaginal de estrógenos liberados por el anillo, crema o tabletas más allá de seis meses.

Duración de la terapia y monitoría

La mejoría de los síntomas de la atrofia vaginal ocurre típicamente a pocas semanas de iniciar la TE vaginal; sin embargo, algunas mujeres necesitan el uso de estrógenos vaginales por cuatro a seis semanas antes de que se vea una mejoría adecuada. Aunque la eficacia parece ser similar para los productos disponibles, las cremas parecen ofrecer una más rápida mejoría y bienestar, aunque algunas usuarias las consideran muy pegajosas. Si hay una estenosis significativa del introito vaginal, una crema de estrógenos usada con un dilatador puede ser necesaria antes de que pueda ser insertado el anillo o la tableta vaginal. No hay datos que sugieran ventaja para el uso inicial de estrógenos vaginales locales y sistémicos al mismo tiempo en el caso de atrofia severa.

Al final, la mejoría subjetiva ocurre en el 80% al 90% de las mujeres tratadas con terapia vaginal local de estrógenos82. La atrofia vaginal que no responda a los estrógenos puede ser debida a dermatosis/dermatitis o vulvodinia no diagnosticada; así pues, la falla al tratamiento requiere una evaluación posterior y un examen cuidadoso.Para mujeres con atrofia vaginal, las dosis bajas locales vaginales de TE deben continuar el tiempo necesario mientras dure el malestar de los síntomas.

No hay datos de seguridad más allá de los 12 meses, pero no se ha establecido límite de tiempo para la terapia. Si una mujer está en riesgo de cáncer endometrial, está usando una dosis alta de TE vaginal o tiene síntomas (manchado, sangrado por derivación), se requiere una vigilancia estricta. En estos casos, algunos clínicos realizan una prueba costo efectiva de progesterona o una ecografía transvaginal particularmente en pacientes de alto riesgo (p. ej. obesas). Sin embargo, los datos son insuficientes para recomendar un control anual en mujeres que usan TE vaginal34,83,84.

Conclusiones y recomendaciones

• Metas primarias en el manejo de la atrofia vaginal son el alivio de los síntomas y la regresión de los cambios anatómicos.
• La primera línea de terapia para mujeres con atrofia vaginal incluye lubricantes no hormonales y humectantes.
• Para atrofia vaginal sintomática que no responde a lubricantes y humectantes vaginales, puede requerirse prescripción de terapia.
• Estudios controlados randomizados en mujeres posmenopáusicas, aunque limitados, han mostrado que estrógenos de dosis bajas locales vaginales son efectivos y bien tolerados para el tratamiento de la atrofia vaginal con absorción sistémica limitada.
• Todos los productos de dosis bajas de estrógenos vaginales locales aprobados para el tratamiento de la atrofia vaginal: crema vaginal de estradiol, crema vaginal de EC, anillo vaginal de estradiol y tableta vaginal de hemihidrato de estradiol son equivalentemente efectivos a la dosis recomendada. La escogencia depende de la experiencia clínica y la preferencia del paciente.
• Los progestágenos generalmente no están indicados cuando dosis bajas de estrógenos se administran localmente para la atrofia vaginal.
• Si una mujer está en alto riesgo de cáncer endometrial, esta usando una dosis mayor de TE vaginal o tiene síntomas (manchado, sangrado por deprivación), se necesita seguimiento estricto. No hay datos suficientes para recomendar un control anual en mujeres asintomáticas que usan TE vaginal.
• La TE vaginal debe continuar tanto como los síntomas persistan.
• Para mujeres tratadas para cánceres no hormonales, el manejo de la atrofia vaginal es similar que para las mujeres sin historia de cáncer. Para mujeres con historia de cáncer hormono-dependiente, el manejo y recomendaciones son dependientes de cada mujer y de su preferencia en acuerdo con su oncólogo.

Soporte comercial

Esta actividad ha sido financiada por una donación educativa irrestricta de Novo Nordisk Inc.

Reconocimientos

La NAMS agradece la contribución especial de los siguientes miembros del Comité Editorial: Gloria A. Bachmann, MD (Chair), Associate Dean for Women’s Health, Professor of Obstetrics and Gynecology and Professor of Medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Director of Women’s Health Institute, Chief of OB/GYN Service, Robert Wood Johnson University Hospital, New Brunswick, NJ; Shawna L. Johnston, MD, Associate Professor, Departments of Obstetrics & Gynaecology and Urology, Chair, Division of Urogynaecology and Reconstructive Pelvic Surgery, Queen’s University.

Kingston, ON, Canada; Bruce Kessel, MD, Associate Professor, Department of Obstetrics and Gynecology, and Women’s Health, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI; M. Tish Knobf, RN, pHD, Associate Professor, Yale University School of Nursing, New Haven, CT; and Elizabeth G. Stewart, MD, Assistant Professor of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA, Director, Stewart-Forbes Vulvovaginal Service, Harvard Vanguard Medical Associates, Burlington, MA. La revisión final fue realizada y aprobada por el Comité Directivo de NAMS 2006-207: Marilyn L. Rothert, pHD, RN, FAAN (President), Professor, College of Nursing, Michigan State University, East Lansing, MI; Victor W.

Henderson, MD, MS (President-elect), Professor, Departments of Health Research & Policy and of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, CA; JoAnn V. Pinkerton, MD (Treasurer), Professor, Department of Obstetrics and Gynecology, Medical Director, The Women’s Place, Midlife Health Center, University of Virginia Health Sciences Center, Charlottesville, VA; Leon Speroff, MD (Secretary), Professor of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR; Thomas B. Clarkson, DVM, Professor of Comparative Medicine, Comparative Medicine Clinical Research Center, Wake Forest University School of Medicine, Winston-Salem, NC; Robert R. Freedman, pHD, Professor, Departments of Psychiatry and Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; J.

ChristopHer Gallagher, MD, Professor of Medicine, Division of Endocrinology, Section of Bone Metabolism, Creighton University Medical School, Omaha, NE; Steven R. Goldstein, MD, Professor of Obstetrics and Gynecology, New York University School of Medicine, New York, NY; George I. Gorodeski, MD, pHD, Professor of Reproductive Biology, Oncology, and pHysiology and BiopHysics, Case Western Reserve University School of Medicine, Case Medical Center, Department of Obstetrics and Gynecology, Cleveland, OH; Risa Kagan, MD, Clinical Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, East Bay pHysicians Medical Group, Berkeley, CA; Nancy K. Reame, MSN, pHD, FAAN, Mary Dickey Lindsay Professor of Nursing and Director, DNSc Program, Columbia University School of Nursing, New York, NY; Isaac Schiff, MD (Ex Officio), Joe Vincent Meigs Professor of Gynecology, Harvard Medical School, Chief, Vincent Memorial Ob/Gyn Service, Massachusetts General Hospital, Editor-in-Chief, Menopause, Boston, MA; Cynthia A. Stuenkel, MD, Clinical Professor of Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, La Jolla, CA; and Wulf H. Utian, MD, pHD (Ex Officio), Arthur H. Bill, Professor Emeritus of Reproductive Biology, Case Western Reserve University School of Medicine, Consultant in Obstetrics and Gynecology, Cleveland Clinic, Executive Director, The North American Menopause Society, Cleveland, OH. The Society also acknowledges the contributions of Ian D. Graham, pHD, Vice-President for Knowledge Translation, CIHR, Associate Professor, School of Nursing, and Associate Professor, Medicine, Epidemiology and Community Medicine, University of Ottawa, Senior Social Scientist, Clinical Epidemiology Program, Ottawa Health Research Institute, ON, Canada; Kathryn J. Wisch, NAMS Managing Editor; and Pamela P. Boggs, MBA, NAMS Director of Education and Development.

Declaración de intereses

La NAMS se asegura de alcanzar un balance, independencia y objetividad en todas sus actividades educativas. A todos aquellos involucrados en actividades de educación médica continuada se les pide que hagan declaraciones de intereses de ellos, sus esposas/esposos, que hayan tenido durante los últimos 12 meses con un interés comercial cuyos productos o servicios son discutidos en la actividad de educación médica o con cualquier financiador de esa actividad sobre el cual ellos tienen control. Por el Comité Editor: Dr. Bachmann reporta: soporte en investigación Berlex, Duramed, Johnson & Johnson, Pfizer, Roche, Wyeth; Conferencista Johnson & Johnson, Wyeth. Dr. Johnston reporta: comité Asesor Paladin Labs Canadá; conferencista Paladin Labs Canadá, Wyeth Canadá. Dr. Kessel reporta: soporte en Investigación Procter & Gamble, Wyeth; conferencista Berlex, Merck, Procter & Gamble, Wyeth. Dr. Knobf reporta: relaciones financieras no significantes. Dr. Stewart reporta: relaciones financieras no significantes. El Comité Directivo de la NAMS reporta la siguiente lista de todas las relaciones financieras no necesariamente las relacionadas con esta actividad educacional: Dr. Clarkson reporta: miembro del grupo en educación hormonal; conferencista Wyeth. Dr.Freedman reporta: Consultor Alexza, Duramed, GlaxoSmithKline, Novartis, Organon, Pfizer, Vela, Wyeth; soporte en investigación Glaxo- SmithKline, National Institutes of Health, Organon. Dr.Gallagher reporta: Consultor, investigador Organon, Pfizer, Wyeth. Dr. Goldstein reporta: Comité asesor EliLilly, GlaxoSmithKline, Merck, Pfizer, Procter & Gamble.

Dr. Gorodeski reporta: Director, Comité Médico Asesor CytoCore. Dr. Henderson reporta: Consultor del grupo de Educación Hormonal Wyeth. Dr. Kagan reporta: comité asesor Merck; Consultor Merck, Roche/GlaxoSmithKline; grupo de Investigación Amgen, Aventis, Eli Lilly, Novartis, Procter & Gamble, Roche/GlaxoSmithKline, Wyeth; Conferencista Merck, Roche/GlaxoSmithKline. Dr. Pinkerton reporta: Consultor Boehringer Ingelheim, Duramed, Merck; Grupo de Educación en Hormonas; MemberVNational Women’s Health Resource Center; soporte para investigación Solvay, Wyeth; Conferencista Merck. Dr. Reame reporta: Consultor Cypress Bioscience, Procter & Gamble; soporte en investigación Novo Nordisk, Procter & Gamble. Dr. Rothert reporta: ninguna relación financiera significante. Dr. Schiff reporta: comité asesor del the consumer magazine of the American College of Obstetricians and Gynecologists; Editor-in-chief de Menopause, la revista official de The North American Menopause Society. Dr. Speroff reporta: Consultor Warner/Chilcott; grupo de Investigación Barr, Berlex, Organon, Wyeth. Dr. Stuenkel reporta: Ninguna relación financiera significante. Dr. Utian reporta: Comité asesor y consultor: Barr/Duramed, Berlex, Depomed, Endoceutics,GlaxoSmithKline, Johnson & Johnson, Merck, Novartis, Organon, Pfizer, Roche/GlaxoSmith- Kline; soporte en investigación: Amylin, Barr, Berlex, Bristol Myers Squibb, Duramed, Eli Lilly, Forest, Galen, GlaxoSmithKline, Johnson & Johnson, Neurocrine, Novartis, Novo Nordisk, Organon, Pfizer, pHarmacia, Procter & Gamble, Roche, Sepracor, Solvay, 3M, Wyeth, Yamanouchi. Para contribuyentes adicionales, Ms. Boggs, Dr. Graham y Ms. Wisch no reportan relaciones financieras significantes.

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