7.2.1 Preparations for vaginal and vulval changes

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 Ovestin.^®
• Vaginal creams may damage latex condoms and diaphragms.
• An impregnated vaginal ring (Estring^®) is also available. It is left in place for 3 months.