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topical HRT (oestrogen) in the management of atrophic vaginitis

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Oestrogen has been used for the management of urogenital symptoms (e.g. vaginal dryness, dyspareunia as a result of vaginal dryness, recurrent urinary tract infection, and urinary frequency and urgency). Alternatives for management are:

  • low-dose vaginal oestrogen such as oestriol (cream or pessary) and/or systemic (oral or transdermal)
  • NICE state that with respect to the management of urogenital atrophy (1)

    • offer vaginal oestrogen to women with urogenital atrophy (including those on systemic HRT) and continue treatment for as long as needed to relieve symptoms

    • consider vaginal oestrogen for women with urogenital atrophy in whom systemic HRT is contraindicated, after seeking advice from a healthcare professional with expertise in menopause

    • if vaginal oestrogen does not relieve symptoms of urogenital atrophy, consider increasing the dose after seeking advice from a healthcare professional with expertise in menopause
    • explain to women with urogenital atrophy that:
      • symptoms often come back when treatment is stopped
      • adverse effects from vaginal oestrogen are very rare
      • they should report unscheduled vaginal bleeding to their GP
    • advise women with vaginal dryness that moisturisers and lubricants can be used alone or in addition to vaginal oestrogen
    • do not offer routine monitoring of endometrial thickness during treatment for urogenital atrophy

Notes:

  • improvement may take several months, and symptoms may recur if treatment is stopped

  • long-term treatment is often required. Low-dose vaginal oestrogen may be preferred if the woman does not wish to take systemic HRT or cannot tolerate systemic HRT

  • endometrial effects should not be incurred and a progestogen is not needed with such low dose preparations
    • however, the endometrial safety of long-term or repeated use of topical vaginal oestrogens is uncertain and the Medicines and Healthcare products Regulatory Agency (MHRA) have advised that treatment with topical oestrogens should be interrupted at least annually to re-assess the need for continued treatment

Note that hese products may damage latex condoms and diaphragms

Topical oestrogen (2)

  • first choice Estriol 0.01% cream (Ortho-Gynest)

Topical oestrogen alternatives (2)

  • Estriol 0.1% cream (Ovestin)
  • Estriol 500 microgram pessaries (Ortho-Gynest)

Initiating and monitoring treatment for topical oestrogens (3)

  • 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

  • use the smallest effective amount to minimise 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

  • it is common to have more vaginal discharge with pessaries and creams, which may be an advantageous side-effect in sexually active women

  • 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

  • there is a lack of long-term data for the use of long-term oestrogen over six months - however at present the long-term low-dose topical oestrogen is not contra-indicated

  • symptomatic relief generally occurs after about three weeks of treatment. Maximal benefit usually occurs after 1-3 months but may take up to a year
    • however, given that the endometrial safety of long-term or repeated use of topical vaginal oestrogens is uncertain and the Medicines and Healthcare products Regulatory Agency (MHRA) have advised that treatment with topical oestrogens should be interrupted at least annually to re-assess the need for continued treatment
    • a pragmatic approach is that the use of topical oestrogen therapy should be reviewed regularly with efforts to reduce or discontinue at 3- to 6-monthly intervals with re-examination

Advise women using topical oestrogen therapy to contact their doctor if they experience any vaginal bleeding

If there is no symptomatic improvement with hormonal treatment, then another underlying cause of for the symptoms should be considered (eg, dermatitis, vulvodynia).

Reference:

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