How do you treat severe vaginal stenosis after radiation in a patient that is already compliant with dilators?

Local estrogen helps a lot. Compliance can be a problem. I suggest that the patient will cover their applicator with estrogen and insert after she goes to bed at night and just leave it in. It will usually come out during the night but this usually beats the patient having to take time out during the day for application.

I'm assuming the patient is already using the dilator daily for at least 20-30 minutes per session. If she is not, that would be my initial recommendation.

Is the vagina agglutinated? Is it limiting pelvic exams as part of surveillance? What is the time frame from the end of RT?

Consider referral to PFPT - there can be a component of vaginal muscle fibrosis that dilators will not help with which can be assessed by PFPTs and managed with exercises and direct stimulation.