Local Estrogen

Local estrogen 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 estrogen 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 estrogen in addition to HRT if needed.

Review at least annually to determine ongoing need and clinical appropriateness, NICE NG23 guides that local estrogen 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 estrogen 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)

For more information on supporting patients with a history of estrogen 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) estrogen varies depending on the type of breast cancer and current adjuvant endocrine therapy (tamoxifen or aromatase inhibitor).

Patients who can usually be prescribed local estrogen:

• 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 (AI)- Unfortunately, this group can get severe GSM symptoms, but the use of local estrogen is controversial as the limited studies we have show conflicting results. Please contact the Somerset Menopause Service by writing to them for more guidance.