Ospemifene

Ospemifene is a tablet for vaginal dryness and painful sex after the menopause. It belongs to a group of medicines called SERMs, short for selective estrogen receptor modulators.

The Pakistan Menopause Society's recommendations describe SERMs as acting like estrogen in some tissues and blocking it in others (section 5.7). So it is not HRT in the usual sense, though it works through the body's estrogen receptors.

The symptoms it is meant for have a medical name, genitourinary syndrome of menopause, or GSM. NICE NG23 counts vaginal and vulval dryness, pain with sex, vulval and vaginal discomfort or irritation, and discomfort or pain when passing urine as genitourinary symptoms.

As estrogen falls around the menopause, the tissues of the vagina and vulva can become thinner and drier. The PMS recommendations call this genitourinary syndrome of menopause, the name that replaced vulvovaginal atrophy (1.5.2), and place it in the first few years after the menopause (Table 1). NICE NG23 groups the dryness with the bladder changes that can come alongside it.

NICE NG23 sets out an order for genitourinary symptoms. For women with no history of breast cancer, vaginal estrogen is the first offer, with non-hormonal moisturisers and lubricants alongside it or instead of it. Vaginal prasterone comes next if those have not helped. Ospemifene is the oral option, for when anything applied locally is impractical (1.5.11). NICE gives disability as its example.

The British Menopause Society goes a step further. It sees ospemifene as a fitting choice for women who cannot use vaginal estrogen, or who would rather take a tablet than use any treatment inside the vagina.

Neither guideline lists ospemifene for hot flushes, night sweats or mood. It is a treatment for one group of symptoms.

It is not for everyone. The European Menopause and Andropause Society (EMAS) says it should not be used by women who have a blood clot now or have had one in the past, and the British Menopause Society advises caution about clots and stroke. Whether it suits you depends on your health history, and that is a conversation for the doctor who would prescribe it.

If dryness, burning or pain with sex has gone on for weeks, it is worth an appointment. It is a medical symptom with medical treatments, and it is not something you have to put up with.

See a doctor promptly if you have any bleeding after sex or after your periods have stopped. The Pakistan Menopause Society lists post-coital and postmenopausal bleeding among the red flags that need checking (section 2.3), whatever treatment you are on.

If it feels impossible to raise, you are not alone in that. The PMS recommendations note that many Pakistani women may not mention sexual or urinary symptoms unless asked respectfully and in private (section 2.2). Writing the symptom down and handing it over is one way in. Asking whether a female doctor is available is another.

For some women the difficulty with vaginal treatments is not physical at all. It is privacy in a shared home, or discomfort with touching or inserting anything, or questions about purity and prayer that they have never asked anyone. Those are real reasons, and the British Menopause Society counts simply preferring a tablet among the reasons to consider ospemifene.

Questions about prayer, wudu or the fast belong with a qualified scholar. Questions about when to take a tablet in Ramadan belong with whoever prescribes it.