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I get to look at this lady every day in my treatment room

Day 2 of Women’s Health Week is devoted to Happy Hormones – here is the link to Jean Hailes’ articles about hormones.  I thought my contribution would be to post some info about when local oestrogen may be advantageous to improved pelvic floor function.

Local vaginal oestrogen can be helpful through different life-stages for women. One of those stages can be whenever you are breast feeding.

Breastfeeding may suppress your monthly menstrual cycle due to high levels of prolactin (a breastfeeding hormone) competing with oestrogen and progesterone production. As time progresses following the birth, the atrophic vaginal tissues can not only impact on prolapse and incontinence, but also may cause dryness and subsequent pain with intercourse. You cease the local oestrogen as soon as you stop breastfeeding.

Another stage is when you become peri-menopausal and post menopausal. It is useful for plumping up the urethral and vaginal tissues which helps with continence control and with comfort in the vagina with penetration during intercourse. Any changes in the ability of the smooth muscle sphincter mechanisms to provide good urethral closing pressure will contribute significantly to stress incontinence and insidious leakage. The urethral sphincter mechanism also deteriorates with ageing due to decreased vascularity and will benefit from oestrogen supplements locally to help after menopause with maintaining urethral closing pressure. Discuss the use of local oestrogen cream or tablets (inserted into the vagina) with your general practitioner or specialist if you are having continence issues or painful sex.

About nine months ago I received a newsletter from HealthEd with an overview on Vaginal Atrophy and Sexual Function. This highlighted the changes suggested by RANZCOG in the method of application of Ovestin, one of the types of local oestrogen.  If you have been prescribed local oestrogen please take note of the Take Home Messages below. After personally changing from Vagifem to Ovestin a couple of years ago, I became aware of the silly design in the applicator supplied with Ovestin. So I was very pleased to read these guidelines which encourage dispensing a small amount of Ovestin cream on your finger – halve one of the doses every second night as this means you lose less and you can avoid using the applicator (which is impossible to clean) and use a finger to apply. Squeeze the cream on your finger, insert low in the vagina – away from the cervix and be sure its on anterior wall and less deep– the half dose also means you don’t lose as much and this will be easier for any arthritic-fingered patients who were worried they couldn’t reach deep enough.
DR JOHN EDEN MB BS MD FRCOG FRANZCOG CREI wrote the following information. Dr John Eden is a certificated reproductive endocrinologist and gynaecologist. He is a Conjoint Associate Professor at The University of New South Wales in Sydney. He is a visiting medical officer at the Royal Hospital for Women, Sydney, Australia where he is Director of the Sydney Menopause Centre and the Barbara Gross Research Unit.
Take Home Messages
  • There is considerable data to support the use of topical oestrogens in urogenital atrophy.
  • Topical oestrogens should not be deposited deep in the vagina, but rather in the anterior portion, in order to minimise uterine exposure and to maximise the effect on the vulva, urethra and clitoral areas.
  • Oestrogen creams may be best used by abandoning the applicator all together and placed on a finger instead. This is then inserted inside the anterior vagina; some cream should also be smeared onto the vulval skin.
  • Patients who have had breast cancer should use nonhormonal moisturisers first and topical oestrogen as a last-resort.
  • Vulval dryness may respond to soap-free washes, using plain moisturisers on the vulva and intravaginal moisturiser products. Natural oils (such as coconut oil or olive oil) can be effective lubricants.
Post-menopause local oestrogen also helps the vaginal tissues with lubrication and thickening to tolerate any sort of supportive pessary (e.g. a ring, cube, Gelhorn or others) to help maintain any prolapse.

Mona Lisa Touch Therapy laser treatment

Since 2013, a non-surgical, non-hormonal alternative to vaginal atrophy has been available in Australia and around the world. This is a laser treatment (Mona Lisa Touch Therapy) which stimulates the body’s regenerative processes to create more healthy and hydrated cells and to improve the vascularity of the vaginal mucosa. I have written a previous blog on the Mona Lisa. It costs around $2000 in Australia for the 3 treatments necessary  and is not covered at all by Medicare at the moment. This may be a useful option if the patient has vaginal atrophy and has had an oestrogen-dependent cancer and is advised not to use local oestrogen. Discuss this with your specialist or doctor.

I hope these titbits help you start some conversations with your medical practitioners.