A 55-year-old postmenopausal woman presents with vaginal dryness, dyspareunia, and recurrent urinary tract infections for 1 year. Examination shows pale vaginal mucosa, loss of rugae, and urethral caruncle. She has no vasomotor symptoms and no personal history of breast cancer. What is the most appropriate first-line treatment?

• A Systemic menopausal hormone therapy (estrogen plus progestogen)
• B Vaginal lubricant alone without any hormonal therapy
• C Oral ospemifene
• D Vaginal low-dose estradiol cream or estriol pessary ✓

Explanation

Genitourinary syndrome of menopause (GSM) is best treated with local low-dose vaginal estrogen (estradiol cream, estriol pessary, or estradiol ring) as first-line when hormonal therapy is indicated. Local estrogen restores vaginal epithelium, increases lactobacilli, and reduces pH with minimal systemic absorption. Systemic MHT is for vasomotor symptoms and is unnecessary here. Ospemifene is a selective estrogen receptor modulator approved for dyspareunia but is second-line. Lubricants provide symptomatic relief but do not treat the underlying atrophy. (NICE NG23; NAMS Position Statement on GSM).

Reference: Comprehensive Gynecology, 8th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.