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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
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 45% to 63% of postmenopausal women have experienced vulvovaginal symptoms, most commonly vaginal dryness. However, symptoms are under-reported and under-treated.
Since the symptoms caused by GSM may have a profoundly negative impact on the quality of life of postmenopausal women, they should be made aware of these problems and treated with an appropriate effective treatment.
Symptoms of GSM may include:
- Vaginal dryness, itching or burning.
- Vaginal discharge.
- Superficial dyspareunia.
- Urinary symptoms and recurrent urinary tract infections (UTIs).
The vulva and vagina typically appear thin, dry and pale.
Preparations containing oestrogen - topical or vaginal hormone replacement therapy (HRT) - are often used to alleviate this condition. They include:
- Vaginal creams.
- Slow-release vaginal tablets.
- Vaginal rings.
The advantage of vaginal treatment is that oestrogen is delivered directly to oestrogen-depleted tissues with similar efficacy to oral oestrogen, but avoiding significant systemic absorption and consequent side-effects.
As drug absorption across the vaginal epithelium avoids the first pass effect, lower doses are required vaginally compared to orally to achieve equivalent plasma concentrations.
- There is good evidence for the efficacy of vaginal HRT in the treatment of menopausal atrophic vaginitis.
- Vaginal symptoms are improved, vaginal atrophy and pH decrease and there is improved epithelial maturation with vaginal oestrogen preparations compared to placebo or non-hormonal gels.
- The different preparations of vaginal HRT (creams, tablets and the estradiol vaginal ring) all appear equally effective for treating vaginal atrophy.
- Vaginal HRT is sometimes used prior to prolapse repair surgery in postmenopausal women with evidence of epithelial atrophy.
- Vaginal oestrogens can be really effective in patients with urinary urgency, frequency or nocturia, urinary incontinence and recurrent UTIs.
- Urge incontinence may be improved by low-dose vaginal oestrogens.
- Topical vaginal oestrogens can be used to treat labial adhesions in girls.
The only contra-indications to use of topical oestrogens are active breast cancer and also undiagnosed vaginal or uterine bleeding. They are otherwise safe. The amount systemically absorbed is very low.
- 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.
Initiating and monitoring treatment
- Establish that there are no contra-indications to vaginal oestrogen therapy - if present, avoid prescribing topical oestrogens or seek specialist advice.
- Use the lowest effective dose to minimise systemic absorption - eg, creams daily for the first two weeks and then reducing to twice weekly.
- Use preparations that have low systemic bioavailability. Efficacy of creams, tablets and vaginal rings is similar.
- Women's individual preference for type of preparation needs to be taken into account. It is common to have more vaginal discharge with creams, which may be an advantageous side-effect in sexually active women.
- Endometrial hyperplasia or adenocarcinoma are extremely rare after long-term use.
- Low-dose vaginal oestrogen does not need to be given with systemic progestogens.
- 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.
- Vaginal oestrogen should be offered to women with symptoms (including those on systemic HRT) and then continued for as long as needed to relieve these symptoms.
- The following should be explained to women::
- Symptoms often return when the treatment is stopped.
- Adverse effects from using vaginal oestrogen are very rare.
- Any unscheduled bleeding should be reported to their GP.
If symptoms have not improved with hormonal treatment, then another underlying cause of for the symptoms should be considered (eg, dermatitis, vulvodynia).
- Non-hormonal moisturisers are a beneficial alternative for those with few or minor atrophy-related symptoms.
- Vaginal lubricants if the main symptoms are pain due to dryness on intercourse.
- They are bioadhesive, non-hormonal preparations.
- Systemic HRT should be considered if flushing and night sweats are also present.
- Systemic HRT fails to resolve vaginal symptoms in 10% to 15% of women and additional vaginal oestrogen may then be needed.
Further reading and references
Faubion SS, Sood R, Kapoor E; Genitourinary Syndrome of Menopause: Management Strategies for the Clinician. Mayo Clin Proc. 2017 Dec92(12):1842-1849. doi: 10.1016/j.mayocp.2017.08.019.
Kim HK, Kang SY, Chung YJ, et al; The Recent Review of the Genitourinary Syndrome of Menopause. J Menopausal Med. 2015 Aug21(2):65-71. doi: 10.6118/jmm.2015.21.2.65. Epub 2015 Aug 28.
Portman DJ, Gass ML; Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. Menopause. 2014 Oct21(10):1063-8. doi: 10.1097/GME.0000000000000329.
Weber MA, Limpens J, Roovers JP; Assessment of vaginal atrophy: a review. Int Urogynecol J. 2015 Jan26(1):15-28. doi: 10.1007/s00192-014-2464-0. Epub 2014 Jul 22.
Calleja-Agius J, Brincat MP; The urogenital system and the menopause. Climacteric. 2015 Oct18 Suppl 1:18-22. doi: 10.3109/13697137.2015.1078206.
Edwards D, Panay N; Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition? Climacteric. 2015 Dec 26:1-11.
Rahn DD, Carberry C, Sanses TV, et al; Vaginal estrogen for genitourinary syndrome of menopause: a systematic review. Obstet Gynecol. 2014 Dec124(6):1147-56. doi: 10.1097/AOG.0000000000000526.
Santen RJ; Vaginal administration of estradiol: effects of dose, preparation and timing on plasma estradiol levels. Climacteric. 2015 Apr18(2):121-34. doi: 10.3109/13697137.2014.947254. Epub 2014 Oct 18.
Menopause: diagnosis and management; NICE Guidelines (November 2015 - last updated December 2019)
No authors listed; Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause. 2013 Sep20(9):888-902