Menopause and Hormone Replacement Therapy: Vaginal and Pelvic Health at Every Age

Menopause causes many unwanted changes to a woman’s body due to a decrease in estrogen production. This drop can lead to pelvic and vaginal pain, dryness, and other symptoms. Women going through menopause may feel like they simply have to accept these changes as a new part of their life, but with hormone replacement therapy (HRT), this is no longer the case. 

In addition to other compounded medications to treat menopausal symptoms, estrogen HRT has been shown in multiple studies to help improve many of the symptoms of menopause. As we’ll discuss in this blog post, it can be administered in a variety of doses and administration routes and can be used to treat either singular or multiple conditions associated with menopause. 

Topical versus Systemic HRT 

When the minimal dose is used for HRT, it has been shown to be helpful for treating the symptoms of menopause and can be used long-term in women over 65 years old (1). There are some instances in which topical administration will be more appropriate than systemic HRT, such as when patients present only one symptom. However, if a patient presents multiple systems (e.g., hot flashes, night sweats, hair loss), systemic HRT may be necessary to address all of them.

Topical HRT

Generally, topical administration is the preferred first route, as the hormone is applied directly to the site of action and can bypass the first-pass effect. It is especially suitable if a patient is experiencing only localized symptoms of menopause or for women who cannot take systemic HRT, such as those at high risk of venous thromboembolism or a history of endometriosis (2,3).

Systemic HRT

Systemic HRT should generally be reserved for women experiencing several symptoms such as night sweats, hot flashes, and other common symptoms of menopause, such as those listed above. It can be administered either via injection, oral administration, or sublingual troches. 

HRT to Restore the Vaginal Microbiome Balance

The vaginal microbiome changes throughout a woman’s life, especially during menopause, when many women will see a decline in Lactobacillus species (4). This leads to an imbalance in vaginal microflora, allowing bacteria responsible for urinary tract infections (UTIs) and bacterial vaginosis to proliferate. Restoring the vaginal microbiome to its pre-menopausal state can reduce the likelihood of these infections. In fact, a randomized controlled trial showed that a group receiving HRT showed improvements in their urogenital symptoms, especially vaginal dryness and sexual issues due to improvements in their vaginal pH and vaginal flora (5).

Low Libido

Perimenopausal and postmenopausal may experience a decreased libido. In menopausal women with fluctuating testosterone levels, those who received both estrogen and testosterone replacement therapy showed increases in their libido (6). Another study confirmed this finding in postmenopausal women with hypoactive sexual drives (7). Testosterone can be administered either orally or via intramuscular injection.

• Testosterone 1 mg/0.12 mL topical cream 
• Testosterone sublingual troche, 0.5 mg

Atrophic Vaginitis

Vaginal atrophy presents when conditions lead to a decrease in estrogen levels. As many as 70 percent of patients may not discuss this condition with their providers due to embarrassment or even a lack of awareness that this is a treatable condition (8). 

Topical vaginal moisturizers, such as hyaluronic acid, may provide relief from this condition(9),  but symptoms may persist in some women, for whom HRT may be necessary. When applied as a vaginal suppository, estradiol was shown to improve the symptoms of dyspareunia associated with postmenopausal atrophic vaginitis in 74 to 82 percent of patients after only two weeks (10). 

In addition to commercially available products, the following compounded preparations can be prescribed to address atrophic vaginitis.

• Dehydroepiandrosterone 13 mg Vaginal Suppository
• Estriol 1 mg/Progesterone 30 mg Vaginal Suppository
• Estriol 5 mg/mL Vaginal Cream
• Acidophilus lactobacillus Vaginal Cream

Vaginal Dryness, Irritation, and Pain

During menopause, the walls of the vagina may become dry and inflamed. To specifically address vaginal dryness (commonly co-occurring with atrophic vaginitis), we offer estriol 0.05% as a vaginal cream.

Vulvodynia

Chronic vulvodynia is seen in up to 38 percent of menopausal women, with many women experiencing this painful condition well into their 70s. Because its symptoms often overlap with other genitourinary symptoms of menopause, it may be underdiagnosed (11).

Why You Should Partner with a Compounding Pharmacy Like VLS Pharmacy and New Drug Loft for HRT

Women no longer need to suffer in silence as they go through menopause. HRT offers a way to mitigate many of the symptoms of these processes to help female patients live life to its fullest, especially in their later years. VLS Pharmacy and New Drug Loft are here to make sure that each HRT regimen meets each woman’s specific needs at every stage of her life.  

Our pharmacists and technicians tailor each formulation to meet a patient’s specific needs, including the dose and administration route. As a 503A pharmacy specializing in sterile and non-sterile compounding, we will support you and your patients by creating individualized pharmaceutical therapies. All formulations are compounded with high-quality pharmaceutical-grade APIs sourced directly from PCCA, the leader of superior-quality APIs.

 

Please comment below with any thoughts or questions.

Reach out to our team to learn about best practices and to partner with our experts on custom compounded medications for your patients. All medications from VLS Pharmacy and New Drug Loft are prepared in a lab that follows safety and quality standards per our status as a 503A pharmacy.

 

References

1. Baik SH, Baye F, McDonald CJ. Use of menopausal hormone therapy beyond age 65 years and its effects on women’s health outcomes by types, routes, and doses. Menopause. 2024;31(5):363-371. doi:10.1097/GME.0000000000002335
2. Tremollieres F, Brincat M, Erel CT, et al. EMAS position statement: Managing menopausal women with a personal or family history of VTE. Maturitas. 2011;69(2):195-198. doi:10.1016/j.maturitas.2011.03.011
3. Goldštajn MŠ, Mikuš M, Ferrari FA, et al. Effects of transdermal versus oral hormone replacement therapy in postmenopause: a systematic review. Arch Gynecol Obstet. 2023;307(6):1727-1745. doi:10.1007/s00404-022-06647-5
4. Muhleisen AL, Herbst-Kralovetz MM. Menopause and the vaginal microbiome. Maturitas. 2016;91:42-50. doi:10.1016/j.maturitas.2016.05.015
5. Ribeiro AE, Monteiro NES, Moraes AVG de, Costa-Paiva LH, Pedro AO. Can the use of probiotics in association with isoflavone improve the symptoms of genitourinary syndrome of menopause? Results from a randomized controlled trial. Menopause. 2018;26(6):643-652. doi:10.1097/GME.0000000000001279
6. Androgen enhances sexual motivation in females: a prospective, crossover study of sex steroid administration in the surgical menopause – PubMed. Accessed July 3, 2024. https://pubmed.ncbi.nlm.nih.gov/4023162/
7. Kingsberg S. Testosterone treatment for hypoactive sexual desire disorder in postmenopausal women. J Sex Med. 2007;4 Suppl 3:227-234. doi:10.1111/j.1743-6109.2007.00449.x
8. Bleibel B, Nguyen H. Vaginal Atrophy. In: StatPearls. StatPearls Publishing; 2024. Accessed July 2, 2024. http://www.ncbi.nlm.nih.gov/books/NBK559297/
9. Dos Santos CCM, Uggioni MLR, Colonetti T, Colonetti L, Grande AJ, Da Rosa MI. Hyaluronic Acid in Postmenopause Vaginal Atrophy: A Systematic Review. J Sex Med. 2021;18(1):156-166. doi:10.1016/j.jsxm.2020.10.016
10. Constantine G, Millheiser LS, Kaunitz AM, et al. Early onset of action with a 17β-estradiol, softgel, vaginal insert for treating vulvar and vaginal atrophy and moderate to severe dyspareunia. Menopause. 2019;26(11):1259-1264. doi:10.1097/GME.0000000000001394
11. Phillips N, Bachmann G. Vulvodynia: An often-overlooked cause of dyspareunia in the menopausal population. Sexuality, Reproduction and Menopause. 2010;8(2). Accessed July 3, 2024. https://www.researchwithrutgers.com/en/publications/vulvodynia-an-often-overlooked-cause-of-dyspareunia-in-the-menopa

 

 

 

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