How do you manage severe vaginal dryness and vulvodynia refractory to topical lubricants in patients with Sjogren's syndrome?

Exclude candida, vestibular gland blockage, and lichen sclerosis.

First-line treatment option is vaginal estrogens (cream, ring) or low-dose systemic estrogen (tablet, patch).

Second-line options include vaginal DHEA or vaginal testosterone.

The severe vaginal dryness in Sjogren's is associated with lymphocytic infiltration, vascular dysfunction, and glandular dysfunction (Nimwegen et al., PMID 32044981).

For persistent vulvodynia, assess for pelvic floor dysfunction, including pudendal nerve and pelvic splanchnic nerve involvement.

Pelvic Floor physical therapy referral and GYN-Urology assessment can assist in localizing the source of chronic pain and additional management options.