HRT - topical vaginal

Oestrogen deficiency of the menopause often causes significant effects on the vagina and bladder, leading to vaginal dryness, and discomfort during sex. This may have an adverse effect on sexual interest, response, sexual function, relationships and quality of life, as well as bladder problems.

Genitourinary syndrome of menopause (GSM) ¹²

Oestrogen deficiency of the menopause often causes significant effects on the vagina and bladder, leading to vaginal dryness, and discomfort during sex. This may have an adverse effect on sexual interest, response, sexual function, relationships and quality of life, as well as bladder problems.

Surveys have shown that around half of postmenopausal women have experienced vulvovaginal symptoms, most commonly vaginal dryness. However, symptoms are under-reported and under-treated; over two-thirds do not discuss this with a healthcare professional. This clinical syndrome is known by a variety of names - urogenital atrophy, genitourinary syndrome of the menopause (GSM) and atrophic vaginitis. The abbreviation GSM will be used in this leaflet.

Management of GSM³⁴⁵

General principles

• Offer low-dose vaginal oestrogen first-line and continue treatment for as long as needed to relieve symptoms. This may be used with systemic HRT and/or with non-hormonal moisturisers or lubricants.

• Two treatments are available which are not vaginal HRT, but are worth mentioning here:

  • Ospemifene may be used second-line, or first-line if the woman cannot use topical treatments, for example due to disability. Ospemifene is an oral selective oestrogen receptor modulator, which acts as an oestrogen agonist in the vaginal mucosa, but as an antagonist in the breast and endometrium. It can be used in women who have finished treatment for breast or endometrial cancer, but not during active treatment.

  • Prasterone may be used second-line; it is a pessary which contains dehydroepiandrosterone (DHEA). Natural levels of DHEA fall in the menopause and the DHEA in prasterone is converted to androgens and oestrogens in the vagina. It is contraindicated if there is a history of breast cancer.

• Treatment should be reviewed annually but can be continued long-term; if the woman wants to periodically try to stop her vaginal oestrogen then she can, but this is not necessary. Systemic absorption is minimal.

• Vaginal oestrogen may help in the management of overactive bladder or recurrent urinary tract infection.

• Most women will have relief of their symptoms after about three weeks of treatment. Maximal benefit usually occurs after 1-3 months but may take up to a year.

• As for all post-menopausal women, any vaginal bleeding should be reported to the GP.

• If symptoms have not improved with hormonal treatment, then another underlying cause of for the symptoms should be considered (eg, dermatitis, vulvodynia).

Management of GSM in women who have had breast cancer ⁶⁷

It is always sensible to communicate with the woman's cancer specialist when prescribing any hormones after treatment for breast cancer, and to take into account other risks for recurrence . The 2024 update of the NICE guidelines on menopause included some principles on the use of vaginal oestrogen in this cohort, who often have severe menopausal symptoms.

• Non-hormonal moisturisers and lubricants should be used first-line, but vaginal oestrogen can be considered, alone or with a non-hormonal moisturiser or lubricant.

• Systemic absorption is minimal, but not zero.

• If the woman's breast cancer was oestrogen receptor negative, it is unlikely that vaginal oestrogen will increase recurrence rates and so it is likely to be safe.

• If the woman's breast cancer was oestrogen receptor positive, we do not know whether vaginal oestrogen will increase recurrence rate; tamoxifen would reduce any such impact.

• If the woman is using aromatase inhibitors, the GP should work with her specialist to identify treatment options where non-hormonal management is not sufficient.

Vaginal oestrogen preparations³

Low-dose vaginal oestrogen can be used in different forms, depending on the woman's preferences:

• Vaginal tablet.

• Vaginal cream.

• Vaginal gel.

• Vaginal pessary.

• Vaginal ring.

A progestogen is not needed for endometrial protection, as systemic absorption of vaginal oestrogen is minimal. The different preparations of vaginal HRT (creams, tablets and the estradiol vaginal ring) all appear equally effective.

Vaginal oestrogen regimens³

Vaginal oestrogen therapy regimens depend on the vaginal preparation used; examples are given below:

• One vaginal tablet daily for two weeks, then reduced to one vaginal tablet twice weekly.

• One applicatorful daily for 3-4 weeks, then reduced to one applicatorful twice weekly, to be applied at bedtime, for cream and gel preparations.

• One pessary daily for three weeks, then reduced to one pessary twice weekly, to be inserted at bedtime.

• One vaginal ring inserted into the upper third of the vagina and worn continuously, to be replaced at three months. Maximum duration of continuous treatment is two years.

Other indications for vaginal oestrogen ¹⁴⁸⁹

• Vaginal HRT is sometimes used prior to prolapse repair surgery in postmenopausal women with evidence of epithelial atrophy. It can also be used short-term prior to cervical screening, if a speculum examination has been uncomfortable in past.

• Vaginal oestrogens can be very effective in patients with urinary urgency, frequency or nocturia, urinary incontinence and recurrent UTIs.

• Topical vaginal oestrogens can be used to treat labial adhesions in girls.

Contra-indications

The only contra-indications to use of topical oestrogens are active breast cancer and also undiagnosed vaginal or uterine bleeding. They are otherwise safe, with the caveat about women using aromatase inhibitors, as discussed above.

Side-effects and risks¹⁰

• Some women (rarely) experience local irritation with the use of topical oestrogens.

• The creams may damage latex condoms and diaphragms; women using these types of contraception should be advised to use either vaginal tablets or the vaginal ring.

• Vaginal oestrogen is not associated with an increased risk of breast cancer.