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7.2.1 Preparations for vaginal and vulval changes

1st choiceEstriol 0.1% intravaginal cream
2nd choiceEstradiol 10microgram pessaries

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.
  • Estradiol pessaries may be useful in women who find creams difficult or messy to use. They are more expensive than estriol 0.1% cream
  • Vaginal creams may damage latex condoms and diaphragms.
  • An impregnated vaginal ring (Estring®) is also available. It is left in place for 3 months.