7.2.1 Preparations for vaginal and vulval changes

ChoiceDrugDosage
1st choiceEstriol 0.1% intravaginal cream (Ovestin®)Dose: Insert one applicator dose daily for 2-3 weeks, then reduce to twice a week (discontinue every 2-3 months for 4 weeks to assess the need for further treatment); vaginal surgery, 1 applicator dose daily for two weeks before surgery, resuming 2 weeks after surgery
2nd choiceEstradiol 10 micrograms vaginal tablets (Vagifem®)Dose: Insert one vaginal tablet daily for 2 weeks then reduce to one tablet twice weekly
Or
Estriol 0.01% intravaginal cream (Gynest®)Dose:
Insert one applicatorful daily, preferably in the evening, until improvement occurs, reduced to one applicatorful twice a week; attempts to discontinue should be made at 3-6 month intervals with re-examination

Prescribing Notes

  • Topical vaginal oestrogen may be used on a short term basis for the treatment of menopausal atrophic vaginitis; systemic therapy is necessary for vasomotor symptoms.
  • It is important to bear in mind that topical oestrogens should be used in the smallest effective amount to minimise systemic effects.
  • The risk of endometrial hyperplasia and carcinoma is increased when systemic oestrogens are administered alone for prolonged periods. The endometrial safety of long-term or repeated use of topical vaginal oestrogens is uncertain. If symptoms of atrophy settle with use, treatment is usually continued at a low maintenance dose of 1-2 times weekly. However, treatment should be reviewed at least annually, with special consideration given to any symptoms of endometrial hyperplasia or carcinoma.
  • Women using long-term vaginal oestrogen treatments do not need to add in cyclical progestogen therapy.
  • Most women with significant vulvo–vaginal atrophy will require long–term treatment particularly if sexually active.
  • Symptoms recur when local vaginal oestrogens are discontinued; there is no fixed duration of use and each woman should be assessed individually.
  • Vagifem® may be useful in women who find creams difficult or messy to use. It is more expensive than Ovestin.®
  • The estriol concentration of Gynest® intravaginal cream is 0.01%. This preparation contains arachis (peanut) oil and is not suitable for patients with peanut allergy. Ovestin® intravaginal cream does not contain arachis oil.
  • Vaginal creams may damage latex condoms and diaphragms.
  • An impregnated vaginal ring (Estring®) is also available. It is left in place for 3 months.