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A case for prophylactic vaginal estrogen?

For many years, the menopause was associated with hot flushes, night sweats and mood swings, with little regard for either the intermediate or long-term consequences of estrogen deficiency. We have now increased the awareness of the later effect of estrogen deficiency on bone density with increasing risk of osteoporosis and we are still learning about the significant effects on the cardiovascular system. Although we have unquestionable evidence that estrogen deficiency leads to significant effects on the urogenital tract, we are still very poor in both identifying and treating the intermediate symptoms. It is thought that urogenital atrophy causes the signs and symptoms of menopause in up to 50% of all postmenopausal women, yet why do only about 25% of those with symptoms seek medical help and, of those, even less receive treatment? Both women and health-care professionals seem to continue to be reluctant or unable to address this serious issue perhaps due to embarrassment, lack of time, acceptance of the symptoms being an inevitable part of ageing or lack of appreciation of the scale of the problem. It was heartening, therefore, to see the International Menopause Society focus on vaginal atrophy with the publication of recommendations, a slide set and patient information leaflets to mark World Menopause Day on 18 October 2010. It is hoped that the surrounding publicity will go some way towards encouraging women to report symptoms of the menopause and health-care professionals to ask appropriate questions when offering menopause counselling, and opportunistically, for example when women are attending for cervical smears. Perhaps we need to take even further measures to really tackle the burden of this problem. We have all seen women with such severe atrophy that even the gentlest of examinations to exclude a serious cause of postmenopausal bleeding is impossible without causing significant discomfort. Many such women may not have been able to be sexually active for many years, living with discomfort, distress and sometimes relationship problems and rejection. At this stage the changes may be irrevocable, whereas earlier treatment may have stopped the progression of the condition, restoring the physiology of the urogenital tract to normal. Why do we allow the vagina to become so fragile and painful when safe effective treatments are available? Why do we still see so many women with postmenopausal bleeding who have to go through the frightening experience of a fast track investigation with the worry of an underlying malignancy when, for so many, vaginal atrophy is the cause? Why do so many women suffer from urinary symptoms and have repeated courses of antibiotics when local estrogen can have such a beneficial effect? Even if these symptoms and presentations are recognized, vaginal estrogen tends to be tarred with the same brush as systemic hormone replacement therapy (HRT) with concerns about risks and uncertainty about duration of use. With more evidence appearing to show that systemic absorption of low-dose vaginal estrogen is minimal, for which progestogenic opposition is not required, perhaps it is time to consider the case for prophylactic estrogen in women who either choose to stop HRT, or do not require HRT at all. If even very low-dose vaginal estrogen is undesired, then a range of lubricants and moisturizers that can ease symptoms are now available. The answer must lie with grasping the opportunity to discuss urogenital health whenever possible, looking for early signs such as flattening of the vaginal walls, and having the knowledge and experience to offer effective treatment, even if symptoms are not yet apparent or are very mild, and to continue treatment for long term, before the changes become untreatable. Menopause International 2010; 16: 135. DOI: 10.1258/mi.2010.010039