Oestrogen is used for the management of urogenital symptoms (e.g. vaginal dryness, dyspareunia as a result of vaginal dryness, recurrent urinary tract infection, and urinary frequency and urgency). Alternatives for management are:
low-dose vaginal oestrogen such as oestriol (cream, pessary or gel) and/or systemic (oral or transdermal)
NICE states that with respect to the management of urogenital atrophy (1)
People with no history of breast cancer
offer vaginal oestrogen to people with genitourinary symptoms associated with menopause (including those using systemic HRT) and review regularly
when discussing the option of vaginal oestrogen, explain that:
serious adverse effects are very rare
their treatment should be reviewed
symptoms often return when vaginal oestrogen is stopped but treatment can be restarted if necessary
vaginal oestrogen is absorbed locally – a minimal amount is absorbed into the bloodstream (when compared with systemic HRT), but this is unlikely to have a significant effect throughout the body
when someone chooses vaginal oestrogen, make a shared decision with the person about whether to use an oestrogen cream, gel, tablet, pessary or ring
advise people with genitourinary symptoms associated with menopause that vaginal oestrogen can be used on its own or in combination with non-hormonal moisturisers or lubricant
for people with genitourinary symptoms in whom vaginal oestrogen preparations are contraindicated, or for people who would prefer not to use vaginal oestrogen, consider non-hormonal vaginal moisturisers or lubricants
consider vaginal prasterone for genitourinary symptoms if vaginal oestrogen or non-hormonal moisturisers or lubricants have been ineffective or are not tolerated
consider ospemifene as an oral treatment for genitourinary symptoms, if the use of locally applied treatments is impractical, for example, because of disability
for the use of vaginal oestrogen in people with genitourinary symptoms and recurrent urinary tract infections, see the recommendations on oestrogen in NICE's guideline on recurrent urinary tract infection (UTI)
People with a personal history of breast cancer
offer non-hormonal moisturisers or lubricants to people with a personal history of breast cancer and genitourinary symptoms associated with menopause
consider vaginal oestrogen for people with a personal history of breast cancer and genitourinary symptoms that have continued despite trying non-hormonal treatments
vaginal oestrogen may be used in combination with a non-hormonal moisturiser or a lubricant
for people currently having aromatase inhibitors as adjuvant treatment for breast cancer, work with a breast cancer specialist to identify treatment options for genitourinary symptoms that have continued despite trying non-hormonal treatments
when assessing the safety of vaginal oestrogens for someone in relation to breast cancer recurrence, take into account all of the following:
the person's general risk factors for breast cancer recurrence
it is unknown whether vaginal oestrogen affects the risks of breast cancer recurrence
vaginal oestrogen is absorbed locally, and some of it is absorbed into the bloodstream but compared with oestrogen from systemic HRT, the amount is minimal
for people with a personal history of oestrogen receptor-negative breast cancer, recognise that any oestrogen systemically absorbed from taking vaginal oestrogen is unlikely to increase the risk of breast cancer recurrence, and so it is likely to be safe
for people with a personal history of oestrogen receptor-positive breast cancer, recognise that:
it is unknown whether any oestrogen systemically absorbed from taking vaginal oestrogen could increase the risk of breast cancer recurrence and
adjuvants that block oestrogen receptors in cancer cells (for example, tamoxifen) would reduce any such potential impact
Do not routinely offer selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs) or clonidine as first-line treatment for vasomotor symptoms alone (1).
Notes:
improvement may take several months, and symptoms may recur if treatment is stopped
long-term treatment is often required. Low-dose vaginal oestrogen may be preferred if the woman does not wish to take systemic HRT or cannot tolerate systemic HRT
endometrial effects should not be incurred, and a progestogen is not needed with such low-dose preparations
advise women using topical oestrogen therapy to contact their doctor if they experience any vaginal bleeding
treatment should be reviewed at least annually - " systemic effects of oestrogen are minimised by using the lowest effective dose to control symptoms; the dose may be increased on the advice of a healthcare professional with expertise in menopause if there is inadequate symptom control. Treatment is continued for as long as needed to relieve symptoms and reviewed initially at 3 months, then at least annually" (2)
if there is no symptomatic improvement with hormonal treatment, then another underlying cause of the symptoms should be considered (eg, dermatitis, vulvodynia).
Note that these products may damage latex condoms and diaphragms
Topical oestrogens - options include (2):
Initiating and monitoring treatment for topical oestrogens (3)
use the lowest effective dose to minimise systemic absorption - eg, pessaries or creams or gels daily for the first two weeks and then reduce to twice weekly
it is common to have more vaginal discharge with pessaries and creams, which may be an advantageous side effect in sexually active women
topical vaginal oestrogen preparations reverse urogenital atrophic changes and may relieve associated urinary symptoms
a review from the Collaborative Group on Hormonal Factors in Breast Cancer (4) “...There appeared to be little risk, however, from topical vaginal oestrogen preparations, which limit systemic exposure.”
use of vaginal oestrogen after diagnosis of breast cancer
a cohort study of 49,237 females with breast cancer, found that there was no evidence of an increase in early breast cancer-specific mortality with the use of vaginal oestrogen therapy compared with no hormone replacement therapy use after breast cancer diagnosis (5)
maximum benefit with these products is usually achieved after around 1–3 months but it can take up to 1 year in some women. Treatment with topical oestrogen should be continued for as long as needed to relieve symptoms as symptoms will often return after treatment is stopped (1) - since the systemic absorption of oestrogen from recommended doses of topical oestrogens is very small (i.e. approximately 1 year's supply of topical therapy contains the same dose as taking a single tablet of oral hormone replacement therapy [HRT]), it is unlikely to be associated with the adverse effects reported with the use of systemic HRT
Contributor/Reviewer:
Dr Louise Newson, GP and Menopause Specialist (July 14th 2020)
for further information about HRT and menopause then see the links below:
All NICE guidance should be viewed in close conjunction with the particular prescribing information (Summary of Product Characteristics) of individual medicinal products cited.
Al-Baghdadi O, Ewies AA; Topical estrogen therapy in the management of postmenopausal vaginal atrophy: an up-to-date overview. Climacteric. 2009 Apr;12(2):91-105
McVicker L, Labeit AM, Coupland CAC, et al. Vaginal Estrogen Therapy Use and Survival in Females With Breast Cancer. JAMA Oncol. Published online November 02, 2023. doi:10.1001/jamaoncol.2023.4508
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