Women in midlife – even those not suffering from hot flashes, mood swings and other well-known symptoms of menopause – may benefit from vaginal oestrogen supplementation. This is because another common, although sometimes less-discussed, symptom of perimenopause and menopause is vaginal atrophy. ‘Atrophy’ refers to the wasting away or diminishing of tissues, and Bleibel (2022) quote that up to 57 per cent of post-menopausal women show vaginal atrophy symptoms. Amongst other things, these include vaginal discomfort, pain during intercourse, problems urinating and increased incidence of urinary tract infections (UTIs) – ouch! Luckily, vaginal oestrogen supplementation can help, and it can be taken without, or in addition to, standard hormone replacement therapy (HRT).
What is vaginal atrophy?
Vaginal atrophy – also known as atrophic vaginitis – is the name given to the condition when the tissues that comprise the wall of the vagina become thinner, drier and inflamed, with diminished elasticity. The vagina loses its pH balance and can also shrink, becoming shorter and narrower.
More recently, the term genitourinary syndrome of menopause (GSM) has been introduced to describe vaginal atrophy in menopausal women due to the common comorbidity of urinary symptoms.
What causes vaginal atrophy?
Vaginal atrophy is most often caused by menopause, due to the associated drop in oestrogen levels that support vaginal and urethral health. This includes both women who have transitioned through natural menopause and those who have experienced early menopause due to some cancer treatments or having their ovaries or uterus surgically removed (oophorectomy and hysterectomy, respectively).
Some symptoms of vaginal atrophy can also arise before menopause if something else causes a drop in oestrogen. Examples are hormonal birth control, childbirth, breastfeeding and taking certain medications. Smoking and some immune diseases can also impact the health of vaginal tissues, as can a lack of sexual intercourse.
What are the symptoms of vaginal atrophy?
Symptoms of vaginal atrophy due to menopausal oestrogen decline can start during perimenopause or years after menopause.
Commonly, the first sign is vaginal dryness due to the drop in natural lubrication and change in acidity that occurs due to falling oestrogen levels. This is often accompanied by itching and burning sensations in the vagina and/or vulva, and pain during sexual intercourse.
Urinary tract symptoms can accompany vaginal ones, because the urethral tissues also thin and weaken with loss of oestrogen. Another consequence is a diminished ability to fight off infections. Issues such as UTIs, pain or a burning sensation while urinating, needing to urinate more often, stress incontinence and an inability to control the flow of urine are all also symptoms of vaginal atrophy.
What are the treatment options?
Depending on the severity of symptoms, there are a few treatment options to consider. It is important to discuss these with your healthcare provider.
Treatments broadly fall under two categories: those that treat the symptoms, and those that supplement the loss in oestrogen. The former treatments are typically moisturisers and lubricants that provide temporary relief. Moisturisers can help with daily vaginal irritation, whilst lubricants are applied before sexual intercourse. Although neither of these restores vaginal health, they may be suitable for those suffering mild symptoms.
Vaginal oestrogen supplementation is the most effective method of treating vaginal atrophy. Used consistently, it reverses the changes in the tissues of the vagina, urethra and vulva and should be considered for more troublesome symptoms. Moisturisers and lubricants can be used in addition to the topical hormone treatment if required.
What form does topical vaginal oestrogen supplementation take?
As the name suggests, vaginal oestrogen supplementation is applied directly into the vagina. It is a low dose and not the same as the oestrogen taken as part of HRT. Vaginal preparations are based on two types of oestrogen: estradiol and estriol. They come in 3 forms:
A topical cream is applied daily for two weeks and twice per week after. The creams can be inserted vaginally with an applicator and also rubbed onto the skin of the vulva which may help soothe irritated skin.
A pessary (suppository) is inserted into the vagina daily for two weeks and twice per week after.
A ring is inserted by the patient, or a clinician if necessary, every 3 months; they are made of soft silicon and provide a slow release of the hormone.
In the UK, examples are Ovestin, Blissel, Imvaggis and Estring.
In the US, examples are Estrace, Vagifem and Femring.
Your healthcare provider will be able to advise which one best suits your symptoms and situation. Sometimes one treatment works better than others, and it may be necessary to try a few to find one that works best for your symptoms.
Benefits of vaginal oestrogen therapy
For women on HRT, the oestrogen it contains may be sufficient to manage any vaginal atrophy symptoms. However, others find that HRT on its own is insufficient to treat such symptoms and require an additional vaginal oestrogen supplement.
Because this is a local (i.e. it is delivered directly to the vagina and does not get absorbed into the rest of the body) and low-dose oestrogen therapy, it may be preferable to HRT for some women who are not suffering any other menopause symptoms other than vaginal atrophy. Additionally, it has minimal adverse effects and may be preferable to those who are concerned about systemic ingestion of hormones.
Some doctors consider it worthwhile for menopausal women to take vaginal oestrogen even if they are not currently experiencing adverse symptoms. This is because some degree of atrophy is expected with advancing age and as the risks are low, they consider it a worthwhile prophylactic.
When will I see an improvement in symptoms?
If the treatment is used consistently, symptoms associated with vaginal atrophy should improve by 3 months. If there is no improvement after this time, it is important to discuss this with your doctor in case your symptoms are due to something else.
What about safety and side effects?
Vaginal oestrogen supplements are considered safe, with serious adverse effects considered unlikely. A 2018 study showed no increase in risk for cardiovascular disease and cancer in women using such preparations. Check with your doctor if, after commencing treatment, you experience breast discomfort, vulval or vaginal itching, pain, burning or redness, headaches, nausea, vaginal discharge, unexpected bleeding or any other unexplained effects.
Do not use the treatment if you are pregnant or breastfeeding.
Women who have had certain cancers or a stroke may not be suitable for this treatment and should discuss alternative options with their doctor.
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