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Many women struggle with vaginal dryness (atrophy) during the menopause. Vaginal dryness is caused by the thinning, drying and inflammation of your vaginal tissues, and can happen as your oestrogen levels fall. Doctors often describe the condition as the genitourinary syndrome of the menopause (GSM).

This article was included in issue 88 (spring 2021) of The Menopause Exchange newsletter.

Signs and symptoms
You may have vaginal dryness, with burning and discharge, genital itching and vaginal infections. Some women have burning when weeing and an urgent and frequent need to pass urine. You may have urinary tract infections and urinary leakage. Other symptoms are light bleeding after sex, discomfort and low vaginal lubrication during sex, and shortening and tightening of your vaginal canal. Many women feel too embarrassed to discuss these symptoms with their GP. But if you have any unexplained vaginal spotting or bleeding, or unusual discharge, burning or soreness, in particular, it’s important to seek medical help.

Self help
A community pharmacist can advise on the different products available without a prescription. For painful sex, try vaginal moisturisers or water-based lubricants. A vaginal moisturiser applied every few days may last longer than a lubricant. Lubricants are applied just before sexual activity and are used to help reduce discomfort during sex. If these products don’t work, see your doctor.

There are many products available. Ask for a product that doesn’t contain glycerin or warming properties if you’re sensitive to these to avoid irritation. If you’re using condoms, avoid products containing petroleum jelly, as petroleum can break down latex condoms on contact.

Smoking affects your blood circulation, causing less blood flow to your vagina and nearby tissues, so stopping smoking may help. Regular sexual activity helps to increase blood flow to your vaginal tissues and makes these more elastic.

Prescribed products
Many women find HRT helps vaginal dryness. If it doesn’t, you may also be prescribed vaginal oestrogen replacement therapy (vaginal ERT). Vaginal oestrogen products contain either oestradiol (estradiol) or oestriol (estriol). You may have some itching and irritation in and around the vagina at the beginning of treatment, but this should settle down. If not, or if you have any vaginal bleeding, this should be checked out by your doctor.

Oestradiol products
Vaginal products containing oestradiol are available as pessaries, vaginal tablets (Vagifem or Vagirux), and a vaginal ring (Estring). Estring remains in place and is changed every three months, and may help with a small lift to the bladder neck.

Vagirux is new, similar to Vagifem vaginal tablets. Both contain 10 micrograms of oestradiol in each tablet. With both products, you’re advised to use an applicator to insert the tablet. This is once daily for two weeks to start with, followed by using it twice a week. With Vagifem, you only use the applicator once. With Vagirux, the same applicator can be washed and reused up to 24 times before throwing it away in household waste. Using the intra-vaginal applicator may cause some local trauma, especially if you have very bad vaginal atrophy. In these women, using vaginal moisturisers to start with may help. Vaginal moisturisers can also be used between doses of the vaginal oestrogen product.

Oestriol products
Products made using oestriol are available as creams (lower dose 0.01% cream or the higher dose 0.1% cream (Ovestin). Newer products include a pessary (Imvaggis) and a vaginal gel (Blissel).

Each Imvaggis pessary contains 0.03 mg of oestriol. You insert the pessary deep into your vagina, preferably in the evening before going to bed. You use a pessary every day for three weeks followed by twice weekly. Imvaggis can’t be used for contraception. It can affect the strength and safety of latex condoms.  Imvaggis contains butylhydroxytoluene, which may irritate your skin, eyes or mucous membranes.

Blissel vaginal gel is applied with an applicator, daily for three weeks and then twice a week, preferably at night. The product is available in different pack sizes. The tubes and plungers may have to be disposed of after use or may be reusable. If reusable, follow the instructions on how to clean them to reduce the risk of infection.

Alternative ingredients
In some women, vaginal products containing pure oestrogen don’t control vaginal symptoms well enough or may not be suitable. There are two new products. Intrarosa contains prasterone (also called dehydroepiandrosterone/ DHEA). DHEA breaks down into oestrogen and androgen hormones. Each pessary is used once a day, at night. It should be inserted as far as it can comfortably go into your vagina, using a finger or applicator. The product has been tested in small 12-week clinical trials and helps improve painful sex. The pessaries are made from hard fat and can cause a vaginal discharge. Cases of breast and ovarian cancer have been reported in clinical trials with women treated with prasterone for 52 weeks. Senshio contains ospemifene. These tablets are taken by mouth with food, at the same time each day. They are used for vaginal dryness and painful sex in postmenopausal women who can’t use vaginal oestrogen replacement therapy. The product hasn’t been studied in women with breast cancer. If used in women with a history of breast cancer, the manufacturers advise it should only be used after all treatment for breast cancer has been completed. Side effects may include hot flushes. Ospemifene doesn’t help to reduce hot flushes due to low oestrogen levels.

About the author
Dr Nuttan Tanna is a pharmacist consultant in women’s health. She runs weekly menopause and osteoporosis medication management clinics at Northwick Park Hospital, in Harrow, Middlesex, and is also actively involved in education and research.

Created Spring 2021

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