Choosing a transdermal oestrogen and tackling genitourinary syndrome of menopause

Transdermal oestrogen products and the management of genitourinary syndrome of menopause are two important topics in menopause management. Selecting the most appropriate treatments should take into account individual needs and preferences. Deborah Evans , prescribing pharmacist and Clinic Director at Remedi Health explains the details.

There are three different formulations of transdermal oestrogen – patches, gels and spray.  Women need to be aware of the pros and cons of each of these so that they can decide which will be best for them. “Patches can be very convenient; you stick them on, you leave them on for three to four days and you change [them]. So, you don’t have to think about your oestrogen replacement in between those times”, explains Mrs Evans.  They are designed to provide a constant level of oestrogen throughout a 24-hour period. “They can be very useful for women who have been suffering an increase in migraines or headaches during their perimenopause because it smooths out the peaks and troughs of their hormone [profile]. The downside is that once we’ve prescribed a particular strength of oestrogen patch then there’s little flexibility to go up and down around that”, she adds. However, once a woman is stabilised on a dose, then the patches can work very well.  “Another downside of the patch is that for women with a very active lifestyle who might be swimming a lot or taking long baths or sweating a lot in the gym, then they can fall off. [Also], some women get irritation from the adhesive”, she says.

“There is also a patch that contains a progestogen which can be helpful for women who might have some compliance issues about taking the sort of micronised progesterone that is part of an HRT regime”, says Mrs Evans.

The gel is very flexible for dosing and it comes in either a sachet or in a pump dispenser. “You apply the gel daily so what you would do is get into a routine that works well for you. Maybe, [take] a shower in the morning, dry your skin very well and then [apply] a couple of pumps of the gel, one on the inside of each thigh; spread over a large surface area, let it dry and get dressed”, explains Mrs Evans. The main downside for gels is the time required for the gel to dry before dressing.

The other formulation is a metered-dose spray which also offers very flexible dosing and dries more quickly than the gel. Women who need more than three-four actuations of the spray can run out quite quickly which may be an important consideration for women who have to pay for private prescriptions.

Genitourinary syndrome of menopause

About 70% of women post-menopause will experience genitourinary problems. These can include weaker bladder, leakage of urine, incontinence and weaker pelvic floor muscles.  Also, women are at risk of urinary tract infections because the microbial flora in that area changes. In addition, there is what used to be called vulvo-vaginal atrophy.  The vulvovaginal and urinary tract symptoms caused by thinning and shrinking of the tissues of the vulva, vagina, urethra, and bladder as a consequence of oestrogen deficiency are now known as ‘genitourinary syndrome of menopause’ (GSM).

Mrs Evans explains: “In the same way that we lose collagen and flexibility in our skin, …..  the skin in our vulva and vagina also declines, becomes thinner. In fact, it can become so thin that women can be prone to bleeding and can get very, very sore. Sexual intercourse becomes incredibly painful if not impossible and they can be prone to vaginal infections, such as thrush. Of course, it’s an area that that women either accept …… or they’re not really thinking about because maybe they’re not as sexually active as they were or they’re just putting it down to old age”.  She also notes that many women in residential care homes suffer from recurrent urinary tract infections which put them at risk of acute kidney injury – partly as a result of lack of appropriate care for GSM. “So, it isn’t just sorting out your dry fanny, this is about making sure that you keep yourself as healthy as you possibly can. It’s super-easy to fix  – systemic HRT … – the topical transdermal oestrogens – will help enormously. But actually, what many women find is that they need local oestrogen so that would be either a cream application or a pessary that they can use and leave in for three months or vaginal pessaries that you insert and that will release oestrogen into the [surrounding tissue]”, she explains.

The amount of oestrogen delivered by these vaginal formulations is very small indeed but it is very effective. “It can change again the cells of the vagina and vulva. It has a local effect on the urethra and the area around the bladder; it can tone up the pelvic floor – although we still need to do our pelvic floor exercises of course. …..  We’ve seen a lot of women who’ve had significant, life-changing [effects] – you know, women that have been nervous to go out because they’ll pee themselves or they have to know exactly where the loo is. Just simply replacing their oestrogen has been enough to address the symptoms”.

“Women with a history of breast cancer can also use these [oestrogen] pessaries because the level is so low that sometimes a woman with a history of breast cancer who can’t use systemic HRT can at least have her GSM sorted out”, she adds.

About Deborah Evans

Deborah Evans is a pharmacist independent prescriber who specialises in women’s reproductive and sexual health, including the menopause. She owns and runs Remedi Health, a clinic in Winchester, Hampshire. She combines the roles of Clinic Director, Superintendent Pharmacist and hands-on practitioner.

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