Vaginal estrogen

Vaginal estrogen is a low dose of estrogen placed inside the vagina, where it acts on the tissues it is put on. Women's Health Concern calls this local HRT, and lists the forms it comes in: a cream, a gel, a tablet, a pessary or a ring.

It is meant for one group of symptoms, which the guidelines call genitourinary syndrome of menopause: vaginal dryness, soreness and irritation, pain during sex, and some bladder and urinary symptoms. The European Menopause and Andropause Society (EMAS) and The Menopause Society, in the US, say it may also help prevent repeat urine infections, and NICE's guideline on recurrent urine infections (NG112) asks doctors to consider it when simpler measures have not worked (1.2.1).

What it does not do matters just as much. The NHS website says it will not treat hot flushes, mood swings or problems sleeping. For those, a doctor would talk about HRT that works through the whole body.

As estrogen falls around the menopause, the tissues of the vagina and vulva can become thinner, drier and more easily sore.

NICE NG23 explains that vaginal estrogen is absorbed locally. Some does reach the bloodstream, but the amount is minimal compared with HRT for the whole body, and unlikely to have a significant effect elsewhere (1.5.6). The NHS website gives that as the reason you do not need a progestogen with it, even if you still have your womb.

NICE NG23 recommends offering vaginal estrogen to women with these symptoms, including women already on HRT, and reviewing it regularly (1.5.5). The doctor and the woman choose the form together (1.5.7), and EMAS considers all licensed vaginal estrogens equally effective. It can be used on its own or with non-hormonal moisturisers or lubricants (1.5.8). For women who cannot or would rather not use it, NICE suggests the moisturisers and lubricants on their own (1.5.9).

The British Menopause Society gives both as options too. It says moisturisers and lubricants can be used alongside vaginal estrogen, that they matter most for women who cannot use estrogen, and that moisturisers work best used regularly, not only around sex.

The Pakistan Menopause Society's recommendations prefer water-based and silicone-based products to glycerine-based ones (6.2), and list vaginal estrogen among the vaginal hormone options, with prasterone (5.5).

If neither suits, NICE lists ospemifene, a tablet, for women who find any treatment applied locally impractical (1.5.11).

The NHS website says it can take up to three months to work fully, and that early side effects such as headache usually settle in the first few months. NICE adds that symptoms often return when it is stopped, and it can be restarted (1.5.6).

After breast cancer

NICE NG23 treats this separately. For women who have had breast cancer, it recommends non-hormonal moisturisers or lubricants first (1.5.14). Vaginal estrogen can be considered if symptoms carry on despite those (1.5.15), and for women taking aromatase inhibitors, the doctor should work with a breast cancer specialist (1.5.16). NICE says it is not known whether vaginal estrogen affects the risk of breast cancer coming back. For estrogen receptor-negative cancer it says any risk is unlikely; for estrogen receptor-positive cancer, unknown, though medicines such as tamoxifen would reduce any such effect (1.5.17 to 1.5.19).

If dryness or pain has gone on for weeks, it is worth an appointment.

See a doctor promptly about any bleeding after sex or after your periods have stopped. The PMS recommendations list both among the red flags that need checking (2.3).

The PMS recommendations note that many Pakistani women may not mention sexual or urinary symptoms unless asked respectfully and in private (2.2). You can write the symptom down and hand it over, or ask whether a female doctor is available.

An applicator, a pessary, a cream: for some women that is simply a medicine. For others it raises questions they have never had to ask before, about modesty, about touching or inserting anything, about wudu and ghusl, or about using it on a fasting day. Women ask these questions, and they rarely get a clear answer.

Questions about prayer, purity and the fast belong with a qualified scholar. Questions about when to use the treatment, or whether a different form would make things easier, belong with whoever prescribes it.