7.2.1 Preparations for vaginal and vulval changes

Topical oestrogens should be used in the smallest effective amount for the shortest duration to minimise systemic effects. Treatment should be evaluated 12 weeks after initiation.

The BNF states that 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; treatment should be reviewed at least annually, with special consideration given to any symptoms of endometrial hyperplasia or carcinoma.

Information on the safety of the following products can be found in the individual manufacturer's Summary of Product Characteristics, which state:

  • For these products for vaginal application, the systemic exposure to oestrogen (estriol / estradiol) remains close to, or within, the normal postmenopausal range; it is not recommended to add a progestogen
  • The risks of breast cancer, endometrial cancer, ovarian cancer, venous thromboembolism, stroke and coronary heart disease should be considered in case of long term or repeated use
  • If bleeding or spotting appears at any time on therapy, the reason should be investigated, which may include endometrial biopsy to exclude endometrial malignancy

Most women will be able to comply with vaginal cream and this should be first choice.

These preparations may damage latex condoms and diaphragms – refer to individual manufacturer's Summary of Product Characteristics.

Formulary guidance on the management of menopause can be accessed here

Estriol cream
  • Intravaginal cream 0.1% providing 0.5mg estriol per applicatorful (30 applications) (£4.45 = 15g)

Indications

Dose

  • 1 applicator-dose daily, at bedtime, for the first weeks (maximally 4 weeks), followed by a gradual reduction, based on relief of symptoms, until a maintenance dosage (e.g. 1 application, at bedtime, twice a week) is reached. Local specialists may recommend alternative doses.

Notes

  1. In order to prevent endometrial stimulation, the daily dose should not exceed 1 application (0.5mg estriol) nor should this maximum dose be used for longer than several weeks (maximum 4 weeks)
  2. Review treatment periodically to assess need for continued treatment
Estradiol vaginal tablet
  • Vaginal tablets 10micrograms (£16.72 = 24 tablets)

Indications

Dose

  • Insert one tablet daily for 2 weeks, reducing to one tablet twice weekly

Notes

  1. Interrupt treatment periodically to assess for continued treatment.
Estradiol vaginal ring
  • Vaginal ring 7.5micrograms/24 hours (£31.42 = 1 ring (3 months treatment))

Indications

Dose

  • Inserted into upper third of vagina and worn continuously; replace after 3 months; maximum duration of continuous treatment 2 years

Notes

  1. Interrupt treatment periodically to assess for continued treatment.

 

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