(Note that this comes from a Pulse Learning module that was actually sponsored by Replens; I hadn’t realised it was sponsored when I clicked on it, so, lesson learned, I will look more carefully in future. It did have some useful points, so I went ahead with the learning; more importantly, it gave a reference for its claims, which I read and which actually made me decide to go with different products for the most part. That kind of backfired on them.)
This problem affects 50% of post-menopausal and 15% of pre-menopausal women. 20% of women on systemic HRT still experience vaginal dryness, so women on systemic HRT might need topical treatment as well. Predisposing factors, apart from the menopause, include:
- Oral contraceptives
- Premature ovarian insufficiency
- Chemotherapy, or aromatase inhibitors
The obvious symptoms are irritation and itching, soreness (including burning pain), and dyspareunia, but note that it can also cause UTI-like symptoms (including urinary incontinence) as well as actual recurrent UTIs.
Examination can show a narrowed introitus, thin mucosa, erythema, and/or petechiae. Investigations are not normally useful; investigate only if you think something else is going on (e.g. if abnormal bleeding present).
I’ve often wondered how often women are supposed to use these, as instructions always seem vague. The answer is that, if they’re used regularly, the effects will last a few days; so using them every 2 – 3 days is often enough.
The module referenced this very useful article on vaginal moisturisers, which advises on what features to look for. The ideal vaginal moisturiser should have both of the following two properties:
- Osmolality <380 mOsm/kg (higher levels can cause irritation to the vaginal walls and damage to the epithelium)
- pH between 3.8 and 4.5, which is the normal vaginal pH. More alkaline environments tend to increase the risk of BV.
(The module tried to claim that moisturisers should aim for a more acid pH – gee, I bet you can’t guess which end of the spectrum Replens’s pH is! – but provided no evidence that this was better or safer than going for normal pH. Might be worth trying if a woman is having a lot of problems with recurrent BV while using vaginal moisturisers.)
This is the kind of lovely concrete advice that I adore. Unfortunately, according to the list they gave, there is only one vaginal moisturiser that fits both criteria; Yes Vaginal Moisturiser. I’m not sure whether this is available on prescription or not.
Because it’s so hard to get moisturisers that fit the criteria, in practice it’s generally considered that anything <1200 mOsm/kg is OK. Which still does not actually broaden the number of available options by much, as most moisturisers are still above that osmolality limit; the only other moisturiser that’s within both this and the pH limit is Sylk. (Canesintima has an osmolality within the higher limit, but quite a high pH.)
Sylk is on the upper limit of the normal pH scale, so, in cases of recurrent BV, it’s probably worth trying Yes, which is slightly better at 4.2. If that doesn’t work, moisturisers with pHs lower than the limit are RepHresh (3.5), Replens (3.0), and Regelle (2.9), all of which unfortunately have osmolalities well above 1200 mOsm/kg.
- Take a few weeks to work
- Don’t require concurrent progestagens
- Can be used for as long as needed
- Vaginal moisturiser might still be needed as well as the topical oestrogen (give at different times).
- Only CIs are active breast cancer or undiagnosed vaginal bleeding.
- Note that PIL will give all the risks of systemic hormones, so warn patients to avoid this!
Whatever treatment you recommend, review at 3/12 to check it’s doing the job, then yearly (NICE guidance).