Treatment of atrophic vaginitis

Treatment of genitourinary syndrome of menopause (GSM) (previously known as vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy)

• malignancy must be excluded
  
  
• non-hormonal treatments
  • lubricants and moisturisers can be used in atrophic vaginitis
    • may be effective in treatment of dyspareunia in women with mild to moderate vaginal dryness
    • useful if contraindication to oestrogen/women does not want to use oestrogen
      
      
• atrophic vaginitis may respond to vaginal oestrogen
  • may be required in addition to oral or transdermal HRT (see linked item)
  • if only vaginal symptoms and no menopausal symptoms then vaginal oestrogen is often used (rather than systemic HRT)
  • approximately 10-25% of women receiving HRT will continue to have symptoms of atrophic vaginitis
  • vaginal creams and gels may be more helpful for vulval symptoms as they can be used intravaginally and with finger application directly onto the vulval skin (1)
  • dose of vaginal oestrogen depends on the preparation of topical oestrogen (2):
    • vaginal tablets (Gina, Vagifem, Vagirux) – insert 1 tablet a day for 2 weeks, then 1 tablet twice a week
    • a vaginal ring (Estring) – insert 1 vaginal ring into the vagina for 3 months
    • vaginal gel (Blissel) – insert 1 dose of gel a day for 3 weeks, then 1 dose twice a week
    • vaginal pessaries (Imvaggis) – insert 1 pessary a day for 3 weeks, then 1 pessary twice a week
    • Ovestin vaginal cream – insert 1 dose of cream a day for up to 4 weeks, then you can reduce your dose gradually depending on symptoms, for example to 1 dose twice a week
    • Ovesse vaginal cream – insert 1 dose of cream a day for 2 weeks, then 1 dose twice a week
      
  • off-licence use of vaginal oestrogen (2)
    • anecdotal evidence suggests that some women may benefit from an extended loading regimen, using vaginal pessaries or creams daily for up to 3 months before reducing the frequency of application
      • in certain cases, symptom control may only be maintained with alternate-day use
    • although systemic absorption is minimal, clinicians should advise patients that evidence supporting the long-term safety of such regimens is limited
      
  • vaginal oestrogen if history of breast cancer (3)
    • can be considered for patients who have completed all treatment for breast cancer, including adjuvant therapy
      • if using tamoxifen, low dose vaginal oestrogen can be considered with advice from the woman’s oncology team or menopause specialist if needed
        • vaginal oestrogens are not advised for patients using aromatase inhibitors; however, where GSM symptoms are significant, insufficiently managed with non-hormonal options and causing patients to contemplate ceasing their adjuvant therapy, they may be considered only after review by the specialist oncology team
          • if available, referral to a menopause clinic is recommended to discuss risks and benefits
      • vaginal oestrogen is safe to use in patients with a history of vaginal, vulval, or cervical cancer
        
• ospemifene is an alternative treatment for atrophic vaginitis

Reference:

1. Burgin J et al. Genitourinary syndrome of menopause. BJGP 2025; 75 (761): 583-585.
2. NHS (Accessed 29/11/25). How and when to use vaginal oestrogen.