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It has been estimated that 4-5 years after the menopause, around 25-50% of women experience symptoms due to atrophic vaginitis. However, only around 24% of these women with symptoms actually seek medical help.
Symptoms 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 HRT) are often used to alleviate this condition. They include:
- Vaginal creams
- Slow-release vaginal tablets
- Vaginal rings
The advantage of this route of administration is that oestrogen is delivered directly to oestrogen-depleted tissues with similar efficacy to oral oestrogen, with the hope of avoiding significant systemic absorption and consequent side-effects. Given some concerns surrounding the safety of systemic HRT, particularly on breast tissue and the coagulation cascade, topical HRT offers a more targeted approach.
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. In practice, systemic absorption is low but not negligible and increases with the dose of oestrogen.
- There is good evidence for the efficacy of topical HRT in the short-term treatment of menopausal atrophic vaginitis. Vaginal symptoms are improved, vaginal atrophy and pH decrease and there is improved epithelial maturation with topical oestrogen preparations compared to placebo or non-hormonal gels. The different preparations of topical HRT (creams, pessaries, tablets and the estradiol vaginal ring) all appear equally effective for treating vaginal atrophy.
- Topical HRT is sometimes used prior to prolapse repair surgery in postmenopausal women with evidence of epithelial atrophy.
- Urge incontinence may be improved by low-dose vaginal oestrogens.
- Topical oestrogens are used to treat labial adhesions in girls.
- Although topical oestrogen can be administered for prevention of UTI, results are still contradictory.
- Oestrogen-dependent cancers.
- Past history of breast cancer - evidence is conflicting but specialist advice should be sought.
- Vaginal low-dose oestrogen treatment may have a role in controlling vaginal atrophy in selected and informed breast cancer women.
- Patients on aromatase inhibitors.
- Active or recent cardiovascular disease.
- Idiopathic or current venous thromboembolic disease.
- Liver disease with abnormal LFTs.
- Untreated endometrial hyperplasia or undiagnosed abnormal vaginal bleeding.
- Women with a peanut or soya allergy should not be prescribed Gynest®.
- Diabetes and other risk factors for heart disease
- Risk factors for oestrogen-dependent tumours - eg, breast cancer in first-degree relatives
- Uterine fibroids (may increase in size)
- Risk factors predisposing to thromboembolism - eg, antiphospholipid syndrome
- Systemic absorption may cause oestrogen-related side-effects such as breast tenderness.
- Endometrial hyperplasia (see below).
- There are limited data looking at the risk of breast cancer or venous thromboembolism specifically associated with vaginal oestrogen delivery. It is generally considered that local preparations are safer because of the very low systemic oestrogen levels associated with their use.
- Some women rarely experience local irritation with the use of topical oestrogens.
The creams and pessaries 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 there are no contra-indications to oestrogen therapy - if present, avoid prescribing topical oestrogens or seek specialist advice, as some systemic absorption will occur.
- Current recommendations are for topical oestrogens to be used in the smallest effective amount to minise systemic effects.
- Use the lowest effective dose to minimise systemic absorption - eg, pessaries or creams daily for the first two weeks and then reducing to twice weekly.
- Use preparations that have low systemic bioavailability. Efficacy of creams, pessaries, tablets and vaginal rings appears equal.
- Women's individual preference for type of preparation needs to be taken into account. It is common to have more vaginal discharge with pessaries and creams, which may be an advantageous side-effect in sexually active women.
- A Cochrane review found that women appeared to favour the estradiol-releasing vaginal ring for ease of use, comfort of product and overall satisfaction.
- Topical vaginal oestrogen preparations reverse urogenital atrophic changes and may relieve associated urinary symptoms.
- There is no evidence that topical oestrogen causes endometrial proliferation after 6-24 months of use.
- Low-dose topical oestrogen does not therefore need to be given with systemic progestogens.
- Although there is still a lack of long-term data for the use of long-term oestrogen over six months, long-term low-dose topical oestrogen is not contra-indicated.
- 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.
- Treatment should be reviewed regularly with efforts to reduce or discontinue at 3- to 6-monthly intervals with re-examination.
Women receiving hormonal treatment should all be advised to contact their doctor if they experience any vaginal bleeding.
If symptoms have not improved with hormonal treatment, then another underlying cause of for the symptoms should be considered (eg, dermatitis, vulvodynia).
- Gynest® 0.01% intravaginal cream (80 g with applicator)
- Ortho-Gynest® 500 microgram pessaries (15 pessaries)
- Ovestin® 0.1% intravaginal cream (15 g with applicator)
- Vagifem® 10 microgram vaginal tablets (24-applicator pack)
- Estring® vaginal ring (releases approximately 7.5 micrograms estradiol/24 hours) - insert high into the vagina and wear continuously. Replace every three months. Maximum duration of continuous use is two years.
- Vaginal lubricants if the main symptoms are pain on intercourse due to dryness.
- Bioadhesive, non-hormonal preparations, such as Replens® or Sylk®.
- Systemic HRT if flushing and night sweats are also present.
- Around 10-25% of women taking oral HRT still have symptoms and so will require topical oestrogen in addition to HRT.
Further reading & references
- Sturdee DW, Panay N; Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010 Dec;13(6):509-22. doi: 10.3109/13697137.2010.522875. Epub 2010 Sep 30.
- Guidelines on Urological Infections; European Association of Urology (Mar 2013)
- Mariani L, Gadducci A, Vizza E, et al; Vaginal atrophy in breast cancer survivors: role of vaginal estrogen therapy. Gynecol Endocrinol. 2013 Jan;29(1):25-9. doi: 10.3109/09513590.2012.705389. Epub 2012 Sep 21.
- Moegele M, Buchholz S, Seitz S, et al; Vaginal estrogen therapy in postmenopausal breast cancer patients treated with aromatase inhibitors. Arch Gynecol Obstet. 2012 May;285(5):1397-402. doi: 10.1007/s00404-011-2181-6. Epub 2012 Jan 3.
- British National Formulary; 65th Edition (Mar 2013) British Medical Association and Royal Pharmaceutical Society of Great Britain, London
- Archer DF; Efficacy and tolerability of local estrogen therapy for urogenital atrophy. Menopause. 2010 Jan-Feb;17(1):194-203. doi: 10.1097/gme.0b013e3181a95581.
- Suckling J, Lethaby A, Kennedy R; Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD001500.
- Ewies AA, Alfhaily F; Topical vaginal estrogen therapy in managing postmenopausal urinary symptoms: a reality or a gimmick? Climacteric. 2010 Oct;13(5):405-18. doi: 10.3109/13697137.2010.500748.
- Al-Baghdadi O, Ewies AA; Topical estrogen therapy in the management of postmenopausal vaginal atrophy: an up-to-date overview. Climacteric. 2009 Apr;12(2):91-105. doi: 10.1080/13697130802585576.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Chloe Borton
Dr Louise Newson
Prof Cathy Jackson