Methods
anogenital squamous lesions, active genital infections, vulvodynia, pain, atrophy, vulvar dermatological disorders, vulvar squamous cell carcinoma, vulvovaginal atrophy
ADVERSE EVENT, RECRUITMENT, VULVODYNIA, ADVERSE EFFECTS, ATROPHY, VULVAR SQUAMOUS CELL CARCINOMA, ATROPHIC
The authors conducted a randomized controlled clinical trial to compare the therapeutic responses to MAFRF treatment with that of vaginal estrogen (Estradiol 3-propyl17β-methyldiether-based) and untreated controls. This study was conducted at a gynecological unit of a public university hospital between July 2020 and September 2022.Participants were selected via referrals from gynecologist physicians at the Januário Cicco Maternity/Federal University of Rio Grande do Norte. The Onofre Lopes Hospital Research Ethics Committee/ Federal University of Rio Grande do Norte approved the trial (81973618.2.0000.5292) and was registered in the Clinical Trials Registry (ReBec) ‒ (RBR-94DX93) Participants were eligible if they were healthy postmenopausal women (55 to 65 years old, with at least 12 months elapsed since their last menstrual period or bilateral oophorectomy), sexually active (at least one vaginal sexual intercourse per week with a partner), with vulvovaginal atrophy (VHI ≤ 15), plasma gonadotropin, and serum hormonal levels in the postmenopausal range (FSH > 40 mIU/mL; estradiol < 25 pg/mL). All women were sexually active and had a normal Pap test and a negative HPV test.Exclusion criteria were patients who used any form of hormonal (systemic or local) therapy in the last six months, lubricants, or vaginal moisturizers in the previous month, with active genital infections tested by real-time multiplex PCR (AnyplexTM II STI-7 Detection). The authors excluded patients with vulvar dermatological disorders, vulvar squamous cell carcinoma precursors, lower anogenital squamous lesions, and vulvodynia. The study flowchart is shown in CONSORT 2010 Flow Diagram.Participants were randomized into one of three treatment arms: MAFRF; Vaginal estrogen: Estradiol 3-propyl 17β-methyldiether; Controls: untreated.The participants were randomized to one of the three arms in a 1:1:1 ratio based on computer-generated randomization (Software Research Randomizer® program). To ensure allocation concealment, an offsite randomization schedule was used. The randomization schedule was prepared in advance by a researcher, who had no contact with any participants throughout the trial and had not been involved in the recruitment, screening, assessment, enrollment, or treatment process. To enroll a participant, the primary researcher sent an e-mail containing the consenting participant's name to the researcher. These details were entered into the allocation spreadsheet, and the subsequent treatment allocation and participant identification number were emailed directly to the treatment.The MAFRF was performed according to the technique described by Kamilos and Borelli.In the vestibule and vaginal opening, 10% lidocaine spray was applied 3 minutes before the procedure. Three applications were performed in the vagina/vaginal introitus, at intervals of 30 days. A sequential application was performed on the vaginal walls under direct visualization. For post-treatment care, a 5% dexpanthenol solution was applied to the vaginal opening twice a day for 2 to 5 days. Subjects were told to avoid sexual intercourse for ten days.Patients in the estrogen group were instructed to use I gm of Estradiol 3-propyl 17β-methyl diether-based vaginal cream, twice a week, for three months.Women in the control group received physician appointments during the follow-up period, where they received clarification about the GSM and guidelines about the principal conducts for managing symptoms provoked by these conditions.At their initial visit, the women answered a standardized questionnaire with baseline demographic data, including age, Body Mass Index (BMI), parity, years since menopause, and prior use of any hormonal therapy. Two relevant time points were considered for evaluating treatment results (days 0 and 90).The primary outcomes were sexual function, evaluated by the Female Sexual Function Index (FSFI), and vaginal health, assessed by the Vaginal Health Index (VHI). Secondary outcomes included composition of the vaginal microbiota (Nugent score) and Vaginal Maturation (MV).The FSFI is a brief scale for assessing female sexual function. It is a written test with six subscales and one sum of scores that measures the degree of desire/excitement/lubrication/orgasm/satisfaction, and pain. The subscales' scores are correlated and added, resulting in a final score. Final scores can range from 2 to 36, and higher scores indicate a better degree of sexual function.The vaginal health score consists of a clinical analysis performed during a speculum-based examination. It measures five parameters (elasticity, fluid volume, pH, epithelial cell integrity and humidity), graded from 1 to 5. The sum of the parameters evaluated results in the total vaginal health score. When the overall rating is less than 15, the vaginal mucosa is considered atrophic.A sample was obtained from the right side wall of the vaginal canal. The swab contents were transferred to a slide and stained by the Gram method. The bacterial morphotypes that were visualized were quantified using Nugent's score. This method classifies bacteria into Vaginal smear samples were collected from the upper distal third of the right lateral wall using an Ayre spatula. Parabasal (P), Intermediate (I), and Superficial (S) cell counts were obtained to determine the degree of atrophy based on the Frost Maturation Index (MI). The MI was then used to calculate the maturation value (MV = [0×%P] + [0.5×%I] + [1×%S]). MV values ranging from 0 to 49 indicate a low estrogen effect, 50 to 64 indicate a moderate estrogen effect, and 65 to 100 indicate a high estrogen effect on the vaginal epithelium. All samples were examined by an experienced cytopathologist blinded to the treatment regimens.All possible adverse effects were recorded and qualified using questionnaires developed for this protocol during treatment. Any breaches of confidentiality, study protocol, or Adverse Events (AEs) attributable to this study were reported to the research ethics committees. The researchers who analyzed the study data were unaware of the treatment applied to any given group.The sample calculation was performed from the effect size of 0.43 obtained from the FSFI score variation.The Shapiro-Wilk normality test was applied to verify the adherence of continuous variables to the normal distribution. The descriptive analysis of the variables that adhered to the normal distribution was performed using the mean and standard deviation (Mean ± SD). For variables that did not present a normal distribution in any of the groups, the median and the 25