Intravaginal estrogen therapy

Intravaginal estrogen pessaries or creams are the most effective treatment for symptoms of vulvovaginal atrophy (vaginal dryness, dyspareunia, urinary frequency, dysuria, nocturia and urgency). They can be used alone or in combination with systemic menopausal hormone therapy (MHT). Nonhormonal therapies for urinary symptoms are needed if urinary incontinence is present.

Intravaginal estrogen therapy should not be started in individuals with undiagnosed vaginal bleeding (including postcoital bleeding, intermenstrual or heavy menstrual bleeding, and postmenopausal bleeding of any severity). Before starting therapy, investigate the cause of vaginal bleeding to exclude estrogen-sensitive conditions such as endometrial cancer. Investigations are the same as those for bleeding during systemic MHT.

Unlike systemic MHT, intravaginal estrogen is not associated with an increased risk of cardiovascular disease or venous thromboembolism, or of developing breast cancer; long-term use is generally considered to be safe. Although intravaginal estrogen has not been shown to increase risk of breast cancer recurrence, nonhormonal options are preferred as initial therapy to manage urogenital symptoms in individuals with a personal history of breast cancer. If symptoms are not managed with nonhormonal treatment, intravaginal estrogen can be used in consultation with an oncology team.

For intravaginal estrogen therapy, use:

Estradiol has a more significant effect on serum estrogen concentration than estriol.

Intravaginal estrogen can improve urinary symptoms by treating underlying vulvovaginal atrophy and reducing the frequency of recurrent urinary tract infections, but it has a limited role in treating incontinence. It may reduce urge incontinence but does not resolve it fully; there is limited evidence for objective benefit in stress incontinence, although some improvement in quality of life is reported. See Nonhormonal therapy for urinary symptoms in menopause.