Table 2.

Clinical Practice Guidelines for Treating Genitourinary Syndrome of Menopause

Presuming No Contraindication to Vaginal Estrogen, in Postmenopausal Women...	Guideline		Grade
1. with a single urogenital atrophy complaint of vaginal dryness, dyspareunia, itching or burning, dysuria, or urinary urgency	we suggest	application of either nonhormonal agents (moisturizers, lubricants) or vaginal estrogen.	2C
2. with a composite of multiple urogenital atrophy complaints (vaginal dryness, dyspareunia, itching or burning, dysuria, or urinary urgency)	we suggest	application of vaginal estrogen instead of nonhormonal agents.	2C
3a. presenting with urogenital atrophy complaints (eg, vaginal dryness, dyspareunia, itching or burning, dysuria, or urinary urgency) also reporting UUI	we recommend	application of vaginal estrogen (agents studied: estradiol vaginal ring and tablet).	1B
3b. for those women whose additional urinary complaints are frequency or nocturia or SUI	we suggest	application of vaginal estrogen.	2C
4a. with urogenital atrophy complaints selecting a vaginal estrogen for treatment	we recommend	application of any commercially available vaginal estrogen at approved doses and frequencies.	1B
4b. and presuming only genitourinary syndrome of menopause complaints and no other indications for systemic estrogen therapy	we suggest	application of vaginal estrogen instead of systemic therapy.	2C
4c. the choice of vaginal estrogen (cream, tablet, ovule, suppository, or ring) may be directed by patient preference, ease of application, or cost			Ungraded
5. with recurrent UTI with or without urogenital atrophy complaints	we recommend	application of vaginal estrogen (agents studied: estradiol vaginal ring and estriol products).	1B
6. with a uterus treated with vaginal estrogen	we suggest	clinician vigilance for possible emergence of endometrial pathology—especially in higher risk patients or those with concerning symptoms.*	Ungraded
7. with personal history of breast or endometrial cancer (or at high risk for either) and bothersome genitourinary syndrome of menopause	we suggest	primary application of nonhormonal moisturizer, but one may consider low-dose vaginal estrogen alternatives after informed understanding of potential risks and balancing of individual preferences and needs.	Ungraded

UUI, urgency urinary incontinence; SUI, stress urinary incontinence; UTI, urinary tract infection.

“Grade” provides a level of strength (1—“strong” or 2—“weak”) to the guideline combining quality of the supporting evidence (A—high to D—very low) with size of net medical benefit. See “Discussion.”

^*Data are insufficient to mandate endometrial surveillance or dictate frequency or means of surveillance.