Luca RONCATI, Dina SADYKOVA
Pelviperineology - 2026;45(2):92-99
Vaginal atrophy (VA) affects about half of the female population in post-menopause, a rate that justifies the growing interest in research, and is due to an estrogen deficiency. This involves dryness, thinning of the epithelium, and a concomitant loss of glycogen in epithelial cells with progressive reduction in the number of glycogen-feeding acidophiles Lactobacilli . The lack of Lactobacilli in turn causes pH alterations and less resistance to infections. If left untreated over the years, VA progresses from mild to moderate and severe forms. Current management is based on hormone replacement therapy (HRT), with the vaginal route of administration being preferred, as it shows fewer side effects and is in direct contact with the mucosa; selective estrogen receptor modulators, particularly ospemifene; selective estrogen enzyme modulators, an example of which is tibolone; and non-HRT interventions. The last ones represent the standards of care in mild VA to be started as early as possible, and a first-line treatment in moderate to severe forms not complicated by osteoporosis as part of a step-up approach. A focus on innovative techniques such as laser, radiofrequency combined with electroporation, and ozone-oxygen therapy is here carried out, together with an excursus on products of proven efficacy virtually free of side effects, i.e., hyaluronic acid, fat-soluble vitamins (vitamins A and E), probiotics ( Lactobacilli ), polynucleotides, exosomes, phytoestrogens (soy isoflavones), monocots ( Aloe vera, Triticum aestivum ), and platelet-rich plasma. Future directions for therapeutic intervention specifically aim to protect women's health and well-being by encouraging research in the field of non-HRT, and its integration with hormonal treatments; in this way, it will be possible to further reduce the minimum effective dose of hormones to be taken, if necessary, by moving from low to ultra-low doses for an increasingly shorter period of time.
