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Genitourinary symptoms (DRAFT)

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Diagnosis

Genitourinary Syndrome of the Menopause (GSM), previously known as vulvovaginal atrophy (VVA) is a common condition affecting menopausal women.

Symptoms include – vaginal dryness, itching, burning, superficial dyspareunia, urinary symptoms, recurrent UTI. Diagnosis is clinical and long-term treatment is recommended.

Remember to consider alternative diagnosis, including STIs or vulval dermatology conditions and provide testing and referral as appropriate.

Management

See BNSSG HRT prescribing pathway

See BNSSG formulary for prescribing options: 7.6 Vaginal and vulval conditions (Remedy BNSSG ICB)

Non-hormonal treatments

Vaginal Moisturisers should be recommended and used liberally, women can buy these OTC. Yes! Vaginal moisturiser can be prescribed for women who cannot be prescribed vaginal oestrogens.

Lubricants should be recommended for sex. Oil based lubricants can affect condom integrity. Oil and water-based lubricants can be used together for a ‘double-glide’ effect.

Pelvic floor physiotherapy - can be considered and women in BNSSG can self-refer : Pelvic Health Physiotherapy Service - msk (bnssg.nhs.uk)

Vitamin E- can be purchased over the counter. A capsule can be burst and the liquid applied directly to the vulva to improve dryness.

Soap Substitutes – can be recommended to improve skin integrity and dryness. Emollients should be used to wash with and ensure adequate moisturisation of the vulva, not just the vagina.

Vaginal Oestrogens

Can be used alone (when symptoms of genitourinary atrophy predominate), or in conjunction with systemic HRT.

Use nightly for 2 weeks and then continue twice weekly.

Twice weekly maintenance doses can be used long-term

Symptoms frequently return on cessation of treatment

Systemic absorption is minimal, and progestogens are not required.

There is no increased risk compared to non-users in the following groups

Breast cancer when all treatment is complete, including adjuvant therapies

Low-intermediate risk endometrial cancer, >6months post-surgery

Vaginal estrogens should not be used by women using aromatase inhibitors.

Some vaginal estrogens and oil-based lubricants can affect condom integrity, increasing the risk of breakage. This should be discussed at time of prescribing.

Formulation	Brand	Contents	Formulary	Comments
Cream	Ovestin	0.1% estriol (500mcg/application)	Green	Beneficial for vulval as well as vaginal symptoms, apply to both. Can occasionally sting. Comes with applicator. Can affect condom integrity, increasing risk of breakage
Vaginal Tablets	Vagirux	10mcg estradiol	Green	Very small tablet. Reusable applicator
	Vagifem	10mcg estradiol	Green	Very small tablet. Disposable applicators
Pessaries	Imvaggis	30mcg estriol	Blue	Metabolised faster, no applicator. Bullet shaped (easier to insert without applicator). More expensive. Can affect condom integrity, increasing risk of breakage.
Vaginal Ring	E-string		Blue	Inserted into upper 3rd of vagina and worn continuously for 3m. Does not need to be removed for SI. Can be inserted above support pessaries. For patients unable to use pessaries or not benefitted from them after several months.

Ospemifene is a selective estrogen receptor modulator licenced for use in GSM in the UK. It is used orally. This is an amber medication and should only be started under specialist services following clinical review.

Prasterone (DHEA) gel may be recommended for those using aromatase inhibitors. This is red on formulary and can only be used in secondary care.

Resources

Patient Resources

25-WHC-FACTSHEET-VaginalDryness-OCT2023-B.pdf (womens-health-concern.org)

23-WHC-FACTSHEET-UrogenitalProblems-OCT2023-B.pdf (womens-health-concern.org)

YES Natural and Organic Intimate Lubricants & Moisturisers (yesyesyes.org)

Vaginal dryness - NHS (www.nhs.uk)

British Dermatology Society PIL Care of Vulval skin - Care-of-Vulval-Skin-Update-February-2020-lay-reviewed-November-2019.pdf (bad.org.uk)

Vulval care (pcds.org.uk)

References

04-BMS-TfC-HRT-Guide-NOV2022-A.pdf (thebms.org.uk)

09-BMS-ConsensusStatement-Urogenital-atrophy-MARCH2024-A.pdf (thebms.org.uk)

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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