34 | Nursing in Practice | Winter 2022
Box 2 Local oestrogen preparations available for GSM treatment 1
estradiol
Estring ( 7.5mcg / 24 hours vaginal ring )
Vagifem ( 10mcg estradiol pessary )
Gina ( 10mcg estradiol pessary )
Box 3 Non-hormonal treatments for GSM 1
Vaginal lubricants YES Sylk estriol
Generic ( 0.01 % vaginal cream )
Ovestin ( 0.1 % vaginal cream )
Vaginal moisturisers Replens Regelle Hyalofemme
The UK Medicines and Healthcare products Regulatory Agency recently announced that an estradiol local vaginal treatment has been reclassified from a prescription-only medicine to a pharmacy-only medicine , meaning it can be bought over the counter ( OTC ) from a pharmacy . This 10mcg estradiol pessary , Gina , is now available to buy for women aged 50 or older who have not had a period for a year , following a consultation with a pharmacist . The pessaries are used daily for two weeks , then twice a week . Each pack costs around £ 29.99 and contains 24 vaginal tablets . Cost may be a consideration for some patients , especially those on low incomes in England who do not usually pay for prescriptions , and those in Wales , Scotland and Northern Ireland where there are no prescription charges . 5
The dose delivered by vaginal oestrogens is very small , and endometrial protection with a progestogen is not necessary 1 , nor is routine endometrial assessment . 4 However , all women should be counselled to seek medical attention should they experience any unscheduled bleeding .
Ospemifene is currently not available in the UK , but is a selective oestrogen receptor modulator that exerts an oestrogen-like effect on the vaginal wall . 1 It appears to be well tolerated with few side-effects , but more research is needed . 3 Intravaginal testosterone and intravaginal dehydroepiandrosterone ( a steroid hormone produced by the body ) are not currently recommended in the UK . 1
Non-hormonal treatments for GSM Non-hormonal treatments include a range of vaginal lubricants and vaginal moisturisers that are available OTC ( see Box 3 ). 1
Vaginal lubricants relieve dryness at the time of intercourse and can be used alone or with local oestrogen . Lubricants should be applied prior to sexual intercourse . However , patients should be warned that some lubricants ( typically those that are oil-based rather than water-based ) can compromise the integrity of condoms and diaphragms .
Vaginal moisturisers are water based and provide longer-lasting relief of vaginal dryness by lining the vaginal wall , mimicking vaginal secretions and lowering the pH . They should be used regularly every few days rather than just before intercourse . 3
The use of phytoestrogens and herbal supplements , such as black cohosh , is not currently supported by evidence of efficacy for GSM . 3
A form of laser treatment showed some benefit for GSM in a small study , but is not widely available , and further research is needed . 3
What about the pelvic floor ? The pelvic floor muscles support the pelvic organs , including the uterus , bladder and rectum . Along with other mechanisms ( such as childbirth and straining ), the pelvic floor can be weakened by the reduction in hormone levels due to the menopause . This can lead to stress incontinence . This may be a problem that women find embarrassing to discuss , so it is worth enquiring about these symptoms when seeing menopausal patients in practice .
Patients should be encouraged to engage in pelvic floor exercises regularly . These exercises can be described as ‘ lift and squeeze ’ – pulling the back passage up and forwards as if you are trying to stop breaking wind , but without clenching the buttocks . Hold the squeeze for up to a count of 10 and release , followed by 10 quick squeezes . These exercises should be repeated three times a day for women experiencing severe symptoms ( although they may need to work their way up to being able to hold on for a count of 10 ).
As symptoms respond to the exercises , they can be done less often but should still be performed regularly . A good tool for women to use is the Squeezy app , which costs £ 2.99 but will help them understand how to perform pelvic floor exercises , as well as sending reminders . 6
Let ’ s talk about sex Average life expectancy for women in the UK is 83 years . 7 A fulfilling sex life does not need to end at the menopause . Female sexual dysfunction may be related to pain and dryness from GSM but there may also be contributions from other menopausal symptoms , such as low mood , altered body image and fatigue due to night sweats . The average age of divorce for women is widely quoted to be around 44 years , and conflict within a relationship may contribute to sexual dysfunction . Although sexual desire and sexual activity tend to decline with age , 26 % of people aged 75-85 may still be engaging in sexual activity , 8 so it is important to support people experiencing challenges in their sex life to ensure they can continue to enjoy sexual relations for as long as they wish .
It is important to consider contraception . Although fertility declines with age , it is still possible to conceive in the perimenopause . The rate of conception for 50-year-old women is variously quoted as between 2 % and 5 %, although this will include assisted conceptions as well as spontaneous pregnancies . If women have previously been having periods , they are advised to continue contraception for at least two years after their last menstrual period if aged under 50 , and at least one year if over 50 . For women who are not having periods ( for example because of a hormonal contraceptive ) the advice is to continue contraception until the age of 55 . 9
The menopause does not protect against sexually transmitted infections ( STIs ), and of course the same advice that would be given to any person regarding STIs should still be given to anyone in the perimenopause and postmenopausally .
References 1 Hillard T et al . Management of the Menopause ( 6th Edition ). Plymouth : British Menopause Society , 2021 2 Portman D , Gass M and the Vulvovaginal Atrophy Terminology Consensus Conference Panel . Genitourinary syndrome of menopause : new terminology for vulvovaginal atrophy from the International Society for the Study of Women ’ s Sexual Health and The North American Menopause Society . Climacteric 2014 ; 17:5:557-563 . bit . ly / 3UTPWcb 3 Angelou K et al . The Genitourinary Syndrome of Menopause : An Overview of the Recent Data . Cureus 2020 ; 12:4 : e7586 . bit . ly / 3AxBE8W 4 NICE . Menopause : diagnosis and management . London : NICE , 2019 . nice . org . uk / ng23 5 British Menopause Society . First clinically proven treatment for vaginal atrophy after menopause to be available for purchase in pharmacy . Marlow : BMS , 2022 . 6 Squeezy . squeezyapp . com 7 Office for National Statistics . National life tables – life expectancy in the UK : 2018-2020 . ONS , September 2021 . bit . ly / 3EmOaJD 8 Lindau S et al . A study of sexuality and health among older adults in the United States . N Engl J Med 2007 ; 357:762-774 9 Women ’ s Health Concern . Contraception for the older woman factsheet . Marlow : WHC , 2019 . bit . ly / 3hXqKms
Dr Rebecca Smithson is a GPSI in women ’ s health in Scotland