Local Oestrogen

Local oestrogen is used to help with vaginal, vulval and urinary symptoms that often develop with low oestrogen levels, this is known as urogenital atrophy, or genitourinary syndrome of the menopause (GSM).

Symptoms can develop any time from perimenopause to many years after the menopause. Symptoms will only get worse without treatment.

Most patients are likely to experience some degree of urogenital atrophy at some point in their lives. Symptoms that occur a long time after the menopause may not be associated with low estrogen, and therefore appropriate treatment may be delayed, or not given at all.

Local oestrogen will be needed on an ongoing basis if there is no systemic HRT in use.  People using systemic HRT may still experience symptoms of urogenital atrophy and can use vaginally delivered local oestrogen in addition to HRT if needed.

Review at least annually to determine ongoing need and clinical appropriateness, NICE NG23 guides that local oestrogen should be used for as long as it is needed to control symptoms.

Some preparations may damage barrier contraception including condoms or diaphragms. People should be aware of this and supported on effective contraception and safer sex including the importance of using lubricants which can be purchased over the counter as self-care.

Local oestrogen does not carry the same risks as systemic HRT so it can be used without taking a progestogen for endometrial protection if used alone, even if the patient still has a uterus. To guide any conversation on risk, use appropriate guidelines, including BMS-

(NICE N23 Dec 19 and BMS Urogenital atrophy Sept 23- March 2024)

Genitourinary Symptoms Associated with Menopause- Visual Summary from NICE NG23 updated 07 November 2024

For more information on supporting patients with a history of oestrogen sensitive cancer, you can seek advice from the Somerset Menopause service by writing to them.

See the main Menopause and HRT page and scroll to “Breast Cancer History or at Risk of Breast Cancer” information for more information and links.

Patients will all need self-care advice on vulval care, vaginal moisturisers as needed and vaginal lubricants during sex.

The advice on the use of local (vaginal) oestrogen varies depending on the type of breast cancer and current adjuvant endocrine therapy (tamoxifen or aromatase inhibitor).

Patients who can usually be prescribed local oestrogen:

• Patients taking tamoxifen
• Patients who have finished or stopped their adjuvant endocrine treatment (usually 5 - 10 years post initial treatment)
• Patients with hormone receptor negative breast cancer

The ultra-low dose estriol products (rather than estradiol) are recommended as first line for these patients i.e. Imvaggis pessaries or Blissel gel.

Patients Taking Aromatase Inhibitors

Unfortunately, this group can get severe GSM symptoms, the use of local oestrogen is controversial as the limited studies we have show conflicting results.

The patient needs to discuss all their treatment options with their oncology team, this may include ultra-low dose local estrogen or a change to tamoxifen if indicated. The Somerset NHS Menopause Service can also provide guidance.

It is recommended that patients on aromatase inhibitors are prescribed YES vaginal moisturiser, to be used daily from the start of their treatment with their aromatase inhibitor. This product is non-formulary for self-limiting conditions but is prescribable for cancer patients who need daily treatment of these products. YES products are considered the preferred choice in this situation.