Insights from outside BJOG

As estrogen levels fall through the menopause transition, women may experience physical changes to their genitalia and these can be accompanied by symptoms such as the genitourinary syndrome of menopause (GSM), vaginal laxity, urinary incontinence or dyspareunia. For these symptoms – specifically GSM – topical estrogen therapy is prescribed. Estradiol vaginal tablets (10 μg) are well tolerated and effective in terms of subjective and objective criteria giving symptomatic relief and improving cytological indicators but it is not clear whether early or late initiation of therapy is more effective. To explore the dilemma an analysis was carried out of a randomised trial in which some women were treated “early” – that is before the age of 60 years and some were treated “late” – starting after the age of 60 years, and their reactions evaluated (Derzko et al. Menopause 2021;28:113–8). It transpires that the earlier therapy starts, the more effective it is. In the words of the researchers “The stronger response observed in younger women supports current clinical recommendations to start treatment early. Continued treatment may be important to avoid recurrence of vaginal atrophy.” These findings of a more rapid and robust response to early treatment beg the question as to whether low-dose vaginal estrogen should not have wider application even in those with mild symptoms, reaching almost a preventative role? (Phillips & Bachmann. Menopause 2021;28:109–10). It is well-known that many women “put-up with” early bothersome vaginal symptoms for reasons of embarrassment or in the belief it is part of a natural process, and the outcomes of low-dose estrogen vaginal tablet therapy suggest this amounts to an opportunity lost in improving the woman’s chances of avoiding symptoms later that could be less amenable to simple treatment. Given the ubiquitous nature of the problem, is it not time for a placebo controlled trial assessing the quality of life (including sexual function/dysfunction) of healthy women through the menopause transition in terms of prophylactic topical estrogen therapy? Since sex is best as a dual pursuit, why not ask the women’s partners what they think? It would be refreshing to hear the men’s view (or the woman’s female partner). Or is that too avant-garde?