In its guidelines for managing menopause, NICE has specific recommendations around vaginal atrophy. It says to offer vaginal oestrogen (including to women on systemic hormone replacement therapy (HRT)) and to continue with this treatment for as long as is needed to relieve symptoms of urogenital atrophy. If symptoms do not respond, it may be appropriate to increase the dose of vaginal oestrogens.¹⁷

If HRT is contraindicated, vaginal oestrogen can still be considered but on the advice of a health professional with expertise in menopause. For example, women who have had a breast cancer diagnosis and are taking an aromatase inhibitor may be advised against using vaginal oestrogen as it may reduce the effectiveness of the aromatase inhibitor.^17,20

Vaginal oestrogen can be administered by vaginal tablet or pessary (the most common choice), cream, gel, or ring. Vaginal oestradiol is available in pessaries and vaginal rings, while estriol is available in pessaries, cream and gel formulations.^21,22

Prasterone or dehydroepiandrosterone (DHEA) is a precursor hormone which is metabolised into oestrogens and androgens. It is licensed as a pessary for VVA in postmenopausal women with moderate to severe symptoms.²³