When vaginal oestrogen is not enough: the next options for dryness and discomfort

Vaginal dryness, soreness, discomfort during sex and recurrent urinary symptoms, grouped together as the genitourinary syndrome of menopause, usually respond very well to a low-dose vaginal oestrogen. But not always, and for the women whose symptoms persist despite it, there are further options worth knowing about. This article covers what comes next, and is a companion to our piece on vaginal oestrogen itself.

First, check the simple things

Before escalating, it is worth making sure the first-line treatment has had a fair trial. Vaginal oestrogen can take several weeks to work, needs to be used regularly rather than occasionally, and is continued long term because symptoms return when it stops. Adding a good non-hormonal moisturiser, used regularly, and a lubricant for sex, can make a real difference alongside it. Sometimes what looks like failure is a treatment not yet given long enough or used often enough.

Prasterone

If symptoms genuinely persist despite proper use of vaginal oestrogen, one option is prasterone, a vaginal pessary containing DHEA, a hormone the body converts locally into small amounts of oestrogen and testosterone right where they are needed. It works in the vaginal tissues with very little reaching the rest of the body. For some women it succeeds where vaginal oestrogen alone has not.

Ospemifene

Another option is ospemifene, which is a tablet rather than a vaginal treatment. It belongs to a group of medicines that act like oestrogen in vaginal tissue without acting like it elsewhere. It suits women who would prefer not to use a vaginal preparation at all, or for whom local treatments have not worked. As with any oral medicine, suitability depends on your wider history.

Where a cancer history changes things

For women with a history of breast cancer, genitourinary symptoms are common, often because of the very treatments that protect against the cancer returning, and they can be among the hardest to live with. The options here are more individual and are chosen in discussion with your cancer team. Low-dose local treatments, including certain very low-dose vaginal oestrogens, may be possible depending on your situation, and non-hormonal measures always remain available. The key is that the door is not simply closed; it is opened carefully and with the right people involved.

A note on vaginal laser

You may have seen vaginal laser treatments advertised for these symptoms. It is not something we offer at present, because the evidence is still developing and we have chosen to focus on the treatments with the strongest evidence behind them. Some clinics do offer it, and if it is something you want to explore, it is worth discussing with a clinic that provides it.

The point

Persistent genitourinary symptoms are common, treatable, and not something to put up with in silence. If first-line vaginal oestrogen has not worked, that is a reason to look again, not to give up. A GP with specific menopause expertise can check it has had a fair trial and step you through the further options sensibly.

Read next

• vaginal oestrogen for dryness and urinary symptoms

• bioidentical hormones what the word means

• who should not take hrt

Ready to start?

If you want to move from reading to acting, the next step is a short assessment with a GP who has specific menopause expertise. It takes about ten minutes and tells you what will help.

Begin your assessment at this link. Online or in person at Westfield London.