As the estrogen levels decrease in menopause, the tissues of the vulva and vagina and around the urethra can become thinner, drier and more fragile. These changes can lead to a variety of uncomfortable symptoms that have a real impact on both physical and emotional well-being and sexual function.

Vulvovaginal atrophy (VVA, atrophy means shrinkage of the tissues) is an very common but often under-recognized issue that affects many women* during the menopausal transition and beyond. Another name for this is Genitourinary Syndrome of menopause, which also recognises that, due to atrophy around the urethra, some people can get urinary symptoms such as increased urinary frequency which can disturb sleep at night. The good news is that these changes and symptoms respond very well to topical oestrogens, which are safe for most people (even when oestrogen tablets, patches or gels are contraindicated).

Symptoms of Vulvovaginal Atrophy

The symptoms of VVA can vary, but often  include:

These symptoms can significantly impact your quality of life, making it difficult to engage in sexual activity and the urinary frequency at night can significantly disrupt sleep for some people. Sleep disturbance in turn tends to worsen flushes, fatigue, brain fog and other menopausal symptoms, so sometimes treating urinary frequency at night can indirectly help with many other symptoms!

Why Standard MHT May Not Be Enough

While standard menopausal hormone therapy (MHT) is usually helpful for almost all menopausal symptoms, it may not be enough to completely or quickly reverse the changes associated with VVA. The good news is that local oestrogen therapy can be highly effective in addressing these symptoms.

The Role of Local Estrogen Therapy

Local estrogens are designed to be absorbed mainly by the tissues where they are applied, with minimal systemic absorption to the rest of the body  (you can read more about the difference between systemic and local oestrogens in another blog article here).

This makes local oestrogen applied to the genitourinary area particularly effective for treating VVA/genitourinary syndrome of menopause without significantly affecting the rest of the body.

For this reason, local estrogen therapy is considered safe for most women*, even most of those who have been advised not to use systemic MHT, such as women with vascular risk factors. In fact, even some women with a previous history of breast cancer can use local estrogen therapy (under the careful guidance of their oncologist/breast surgeon/breast physician). The main exception is women who are still on active therapy for breast cancer, particularly with an aromatase inhibitor for recent breast cancer -for these women* using non-oestrogen containing vaginal moisturiser are recommended.

In New Zealand, Ovestin cream is funded and the most commonly used brand of local estrogen treatment for VVA, available on prescription. It’s available in both cream and pessary forms. However, we usually recommend starting with the cream, as the pessary can be uncomfortable to insert when there is severe dryness. The cream also allows application to the inner vulva and urethra in addition to the vagina.

How to Apply Ovestin Cream for Optimal Results

While the manufacturer’s instructions suggest inserting Ovestin cream into the vagina using an applicator, we find a slightly different application process even more beneficial for treating the full range VVA symptoms, including vulvar dryness, reduced sensitivity and urinary symptoms.

1. Using the Applicator: Use the applicator to draw up the correct amount of cream.

2. Application: Apply a thin layer to the lower third of the vagina, the inner vulva, and the urethra. It’s important to include application of  the cream directly to the urethra if you have urinary symptoms.

3. Consistency is Key: For best results, use the cream very regularly—every night for two weeks, then twice weekly for at least three months.

If you have trouble remembering to apply the cream, consider setting a nightly alarm after your shower to make it part of your routine. If you’re engaging in intercourse at night apply the cream after cleansing  the area, just before going to sleep.

Managing Sensitivity to Ovestin 

Some people may experience stinging or sensitivity when first applying Ovestin cream. If this happens, try using an active ingredient-free vaginal moisturizer, such as NatFem Balm or Replens, for a couple of weeks to prepare and hydrate the area before trying the estrogen cream again.

For those who struggle with remembering to consistently use the cream or pessary, the **Estring ring** can be an alternative (but is not government funded in New Zealand). It’s a silicone ring that releases a low dose of estrogen over three months. The Estring is usually about $200 NZD provided by prescription by some pharmacies such as  Bays Health Pharmacy or via placement by a gynecologist at Omnicare Women’s Health. If needed for urinary symptoms, you could apply a pea-sized amount of Ovestin cream to the urethra (every night for 2 weeks then twice weekly) even if you’re using the Estring

Our colleague Dr. Lisa Meyer is a very experienced gynecologist who frequently places Estring rings for women. Below, she shares her insights on the pros, cons, and benefits of the Estring, and discusses when it might be the most appropriate choice for managing VVA symptoms. 

Dr Meyer has help women with VVA symptoms by inserting the Estring,  for more than 7 years now.  She comments:

 “ Firstly for some women, this ring has been a life-changer when they could not use Ovestin cream or pessaries due to vaginal sensitivity to the substances (the cream or solid pessary) that contain and deliver the oestrogen locally. The inert silicone that houses the reservoir of oestrogen does not have that sensitivity effect.

Secondly, the convenience of a 3 month continuous delivery of oestrogen is a huge benefit for women who travel a lot, are forgetful or are not physically able to insert the applicator or pessary.

Lastly, women who have used tampons in the past, often find inserting and removing the flexible ring easy. I show them how to do this themselves at the 3 month visit after the initial Estring insertion.  We do provide the option of 3 monthly visits to have the Estring changed by  our Specialist GP in women’s health, Dr Anna Twhigg, at Omnicare Women’s Health (who also works at ERH Associates),  for those who would prefer that.

Unfortunately, Estring is not for everyone. Similar to the oestrogen in Ovestin, the oestrogen released by the ring can interfere with aromatase inhibitors, a drug used in the treatment of breast cancer. The oestrogen is contraindicated while women are taking the aromatase inhibitor. When they are no longer on this drug, the Estring can be used safely for those with VVA symptoms.

The Estring may also not be suitable in women with weak pelvic floor muscles and vaginal prolapse. This can cause the Estring to fall out.”

Long-Term Use and Monitoring

Ovestin cream can be used alongside standard systemic menopausal hormone therapy (MHT), and there is no upper age limit for Ovestin use. You can continue using it indefinitely if needed.  Sometimes once the VVA symptoms have improved with a 3 month course of Ovestin, systemic MHT might help to prevent VVA from coming back so you may be able to stop using Ovestin whilst continuing MHT. If you stop Ovestin and/or MHT and notice symptoms of VVA coming back, consider  restart the cream sooner rather than later since it can take weeks to months to reverse the changes once they occur.

Don’t Suffer in Silence

Vulvovaginal atrophy/Genitourinary Syndrome or Menopause is very common but under-recognised – and it’s important to know that effective treatments are available. If you’re experiencing symptoms, don’t hesitate to talk to your doctor. Regular use of local estrogen therapy, can significantly improve your comfort and quality of life. Vulvovaginal moisturisers can be used before or alongside local oestrogen and vulvovaginal moisturisers are the main treatment for women with VVA who are on an aromatase inhibitor as treatment for previous breast cancer. Personal lubricants (eg. Sylk, Astroglide) can also be helpful during intercourse. VVA is such an important and distressing, but usually easily treatable condition that we wanted to share as much of the information that we provide in our consults on this topic with you in this article. But if you have bleeding with intercourse, symptoms persist despite local oestrogen treatment or you have other vulvovaginal symptoms such as itch, it is important to see your doctor for an examination to check for other causes (more on this in our next blog featuring Dr Harriet Kennedy, a dermatologist with expertise in vulval health).

Dr Lisa Meyer is a general gynaecologist with a special interest in ultrasound. Born in South Africa, Lisa completed medical training at the University of Pretoria. Her background includes two years of obstetric and gynaecological ultrasound at Tygerberg Hospital, Cape Town; and the university of Stellenbosch.

Lisa pursued her interest in fetal medicine and high risk obstetrics in London, UK; where she trained with internationally renowned consultants in all fields of O&G. She is a Fellow of the Royal College of Obstetricians and Gynaecologists, Fellow of the Royal College of Physicians and Surgeons of Canada, Fellow of the Royal New Zealand and Australian College of Obstetricians and Gynaecologists, a member of Australia Society of Ultrasound in Medicine and is accredited with the Diploma in Diagnostic Ultrasound. Lisa has been involved in the Fetal Medicine Foundation Nuchal Translucency Study for the ultrasound detection of Down’s Syndrome.

Lisa has been in private practice in New Zealand since 2002 and set up Sonelle Women’s Ultrasound in 2010. She is passionate about the provision of excellence in ultrasound in Womens Health, and wished to see an ultrasound unit with womens health as a primary focus.

Learn more about Dr Lisa Meyer, gynaecologist and Omnicare here

For more in-depth guidance through evidence-based information as well as practical self-care during menopause, join the waitlist for our upcoming Menopause app-based course. Our course will provide a step-by-step approach through, scientific medical information as well mindset strategies, and practical tips to help you navigate menopause with confidence. We will be announcing the course launch date soon! 

For personalised medical care around the hormonal aspects of menopause ask your doctor for a referral to ERH Associates

women*: assigned at birth female