Hormonal compounds that have been studied recently include estetrol, an oestrogen produced in foetal liver with selective tissue activity. Given orally, estretol can improve vaginal tissue and vaginal dryness as well as other menopausal symptoms, with a subsequent improvement in quality of life. However, it is currently only available in the UK in a combination oral contraceptive.^8,30

Ospemifene is indicated for treating moderate to severe VVA symptoms in post-menopausal women where local vaginal oestrogen therapy is not suitable. It binds to oestrogen receptors where it can activate oestrogenic pathways in some tissues, including in the vagina, but block other oestrogenic pathways, such as in mammary tissue.^31,32

The Scottish Medicines Consortium/Health Improvement Scotland assessment in 2019 recommended its use as the drug is associated with significant improvements in vaginal tissue maturation and pH, as well as patient symptom scores for vaginal dryness and dyspareunia.³³

Manipulating the vaginal microbiome is another area that has potential. Probiotics – oral or intravaginally – may help reduce VVA symptoms in postmenopausal women and enhance the effect of oestrogen therapies.^34,35

Physical treatments for genitourinary symptoms of menopause include laser and radiofrequency procedures, although effectiveness and safety are still being studied.^34,36,37