Estriol

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Estriol on Prescriptsy

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Estriol is a topical vaginal oestrogen used to treat genitourinary syndrome of menopause (GSM), a condition previously known as vulvovaginal atrophy or atrophic vaginitis.

GSM encompasses the vaginal, urethral and bladder symptoms caused by oestrogen deficiency after the menopause, including vaginal dryness, itching, burning, discomfort during intercourse (dyspareunia), urinary frequency, urgency and recurrent urinary tract infections.

Estriol is available in the UK as vaginal cream (Ovestin cream, 1 mg/g) and pessaries (Ovestin pessaries, 0.5 mg).

It is a prescription-only medicine (POM) and is one of the most commonly prescribed local vaginal oestrogen preparations in UK general practice.

Genitourinary syndrome of menopause affects an estimated 50 to 70% of postmenopausal women, yet it remains significantly underdiagnosed and undertreated.

Unlike vasomotor symptoms (hot flushes and night sweats), which often improve spontaneously over time, GSM tends to be progressive and will not resolve without treatment.

The vaginal and urethral tissues are highly sensitive to oestrogen, and when oestrogen levels decline at the menopause, these tissues become thin, dry, less elastic and more vulnerable to infection and mechanical trauma.

Many women suffer in silence, either unaware that effective treatment is available or reluctant to discuss intimate symptoms with their GP.

This page provides a comprehensive clinical overview of estriol vaginal preparations, including how they work, how to use them, expected benefits, safety information, and how to obtain a prescription in the United Kingdom.

Important safety information about estriol

Before reading further, note the following essential safety points.

• Estriol vaginal preparations are prescription-only medicines and should be used as directed by your prescriber.
• A progestogen is NOT required alongside low-dose vaginal estriol, even in women with an intact uterus.
• Vaginal estriol is NOT a form of systemic HRT and will not treat hot flushes or night sweats.
• Report any unexpected vaginal bleeding to your GP promptly for investigation.
• The systemic risks of HRT (blood clots, stroke, breast cancer) do not apply to low-dose vaginal oestrogen.

Understanding genitourinary syndrome of menopause

The vagina, vulva, urethra and bladder base all contain oestrogen receptors.

In premenopausal women, oestrogen maintains the thickness, elasticity and moisture of the vaginal epithelium, supports a healthy Lactobacillus-dominant vaginal microbiome (which produces lactic acid and maintains an acidic pH of 3.5 to 4.5), and maintains the collagen and blood supply of the vaginal and urethral tissues.

After the menopause, oestrogen deficiency leads to thinning of the vaginal epithelium, loss of rugae (folds), reduced blood flow, decreased lubrication, rise in vaginal pH (to 5.0 to 7.0), loss of Lactobacillus dominance, and an increased susceptibility to pathogenic bacteria.

The urethral and bladder tissues also atrophy, contributing to urinary symptoms.

Symptoms of GSM include vaginal dryness, itching, burning, soreness, pain during intercourse (dyspareunia), reduced sexual arousal, urinary frequency, urgency, nocturia, dysuria (painful urination) and recurrent urinary tract infections.

These symptoms are chronic and progressive; without treatment, they worsen over time and can severely affect sexual function, intimate relationships, self-confidence and quality of life.

NICE guideline NG23 recommends offering vaginal oestrogen to women with urogenital atrophy, including those on systemic HRT if systemic treatment alone is not controlling vaginal symptoms.

Non-hormonal vaginal moisturisers and lubricants may provide temporary symptom relief but do not reverse the underlying mucosal changes. Vaginal oestrogen is the definitive treatment for GSM.

How estriol works: mechanism of action

Estriol (oestriol) is one of three naturally occurring oestrogens in humans, alongside estradiol and estrone.

It is the weakest of the three, with a short receptor occupancy time of approximately 1 to 4 hours (compared with 6 to 24 hours for estradiol).

When applied intravaginally, estriol binds to oestrogen receptors in the vaginal epithelium, stimulating cell proliferation, thickening the mucosa from a few cells deep back to the normal 20 to 40 cell layers, increasing glycogen content (which feeds Lactobacillus bacteria), restoring the acidic vaginal pH, and improving blood flow and lubrication.

Because estriol has a short duration of receptor binding and is applied locally in small doses, systemic absorption is minimal.

Plasma estriol levels after vaginal application remain within or close to the normal postmenopausal range, particularly after the initial treatment phase (the atrophic mucosa absorbs more than healthy tissue).

This low systemic exposure means that vaginal estriol does not cause clinically significant endometrial stimulation and does not carry the risks associated with systemic oestrogen therapy.

Clinical evidence and UK prescribing guidance

Multiple randomised controlled trials and systematic reviews have confirmed the efficacy of vaginal estriol in treating GSM symptoms.

A Cochrane review of intravaginal oestrogen for vaginal atrophy concluded that all forms of local vaginal oestrogen (cream, pessary, tablet, ring) are effective in relieving symptoms of atrophy, with no significant differences in efficacy between preparations.

Patient preference and ease of use guide the choice of formulation.

Estriol vaginal cream and pessaries have been shown to restore vaginal cytology (increasing the proportion of superficial and intermediate cells), lower vaginal pH, increase vaginal moisture and elasticity, reduce dyspareunia, and reduce the frequency of recurrent urinary tract infections.

Symptom improvement is typically noted within 1 to 3 weeks, with full benefit by 4 to 12 weeks.

NICE NG23 states that vaginal oestrogen should continue for as long as symptoms persist, which may be indefinitely.

The guideline notes that a progestogen is not required alongside low-dose vaginal oestrogen.

The MHRA has confirmed that the safety concerns associated with systemic HRT do not apply to local vaginal oestrogen at standard doses.

The British Menopause Society, the Royal College of Obstetricians and Gynaecologists (RCOG), and the International Menopause Society all endorse the long-term use of vaginal oestrogen for GSM, emphasising its excellent safety profile and the importance of treating this common and debilitating condition.

How to use estriol vaginal cream

Ovestin cream (1 mg estriol per gram) is supplied with a calibrated applicator. Fill the applicator to the 0.5 g mark (delivering 0.5 mg estriol).

Lie down and gently insert the applicator into the vagina as far as is comfortable. Press the plunger to deposit the cream.

Remove the applicator and wash it with warm water and mild soap. Use at bedtime to allow the cream to remain in contact with the vaginal tissue overnight.

During the initial loading phase, apply once daily for 2 to 3 weeks. Then reduce to twice-weekly maintenance application.

If a small amount of cream is applied to the external vulvar area for vulvar dryness, use sparingly. Treatment may be continued indefinitely.

How to use estriol pessaries

Ovestin pessaries (0.5 mg estriol) are inserted intravaginally using the applicator provided. Lie down, insert the applicator gently, and release the pessary. Use at bedtime.

During the initial phase, insert one pessary daily for 2 to 3 weeks. Then reduce to one pessary twice weekly for maintenance. Clean the applicator after each use.

What to expect during treatment

Most women notice improvement in vaginal dryness and comfort within 1 to 3 weeks. Improvement in urinary symptoms may take longer (4 to 12 weeks).

If you stop treatment, symptoms will return as the vaginal mucosa reverts to its atrophic state.

This is why continuous long-term use is recommended for women with ongoing symptoms.

Side effects of estriol vaginal preparations

Common local side effects

Mild vaginal irritation, burning, itching or increased discharge may occur during the first few days of treatment. These effects are usually transient and settle as the vaginal mucosa responds. If irritation persists, contact your prescriber.

Uncommon side effects

Breast tenderness has been reported uncommonly and may reflect slight systemic absorption during the initial loading phase when the atrophic mucosa is more permeable.

This typically resolves as the vaginal epithelium thickens. Vaginal candidiasis may develop as the vaginal environment changes; treat with standard antifungal therapy if symptoms arise.

Vaginal bleeding

Any vaginal bleeding in a postmenopausal woman must be reported to your GP, even if you think it may be related to estriol treatment.

Your doctor will arrange investigation (typically transvaginal ultrasound to assess endometrial thickness) to exclude endometrial pathology. Bleeding with low-dose vaginal estriol is rare.

Systemic risks

The risks associated with systemic HRT (venous thromboembolism, stroke, breast cancer, endometrial cancer) do not apply to low-dose vaginal estriol.

NICE, the MHRA, and the British Menopause Society all confirm that local vaginal oestrogen is safe for long-term use without the need for a progestogen.

This has important practical implications: women who cannot take systemic HRT (for example, due to a history of VTE or breast cancer) may still be able to use vaginal oestrogen, though this should be discussed with their specialist.

When to seek medical advice

Contact your GP if you experience unexpected vaginal bleeding, persistent irritation or burning, breast tenderness that does not resolve, or any symptom that concerns you.

Report any suspected adverse reactions to the MHRA via the Yellow Card scheme at yellowcard.mhra.gov.uk .

Warnings and precautions

Contraindications

Estriol vaginal preparations should not be used in women with known or suspected breast cancer, known or suspected oestrogen-dependent malignancy, undiagnosed vaginal bleeding, untreated endometrial hyperplasia, or hypersensitivity to estriol or any excipient.

Breast cancer survivors

The use of vaginal oestrogen in breast cancer survivors is a nuanced clinical decision.

While systemic absorption from vaginal estriol is very low, some oncologists prefer non-hormonal alternatives (vaginal moisturisers, hyaluronic acid-based products) as first-line treatment.

If non-hormonal options are insufficient, vaginal oestrogen may be considered after discussion with the patient's oncology team, taking into account the type of breast cancer, current endocrine therapy (such as aromatase inhibitors, which are particularly associated with vaginal atrophy) and individual risk-benefit assessment.

Effect on latex

The oily base of estriol cream and pessaries may weaken latex condoms and diaphragms. Wait at least 72 hours after application before using latex barrier contraception, or use non-latex alternatives.

Not a contraceptive

Estriol vaginal preparations do not prevent pregnancy. If contraception is needed (for example, in perimenopausal women), use an appropriate contraceptive method in addition to vaginal estriol.

How to get estriol in the UK

Estriol vaginal cream and pessaries are prescription-only medicines. Your GP can prescribe them following a straightforward clinical consultation.

No internal examination is usually necessary to start treatment, though your GP may wish to perform one if there are any diagnostic concerns.

Authorised online prescribers registered with the GPhC can also prescribe estriol following a structured consultation.

The NHS prescription charge in England is currently 9.90 pounds per item; prescriptions are free in Scotland, Wales and Northern Ireland.

If you are experiencing vaginal dryness, discomfort during intercourse or urinary symptoms since the menopause, do not hesitate to discuss these with your GP.

GSM is a medical condition with a safe and highly effective treatment, and there is no need to suffer in silence.

Practical tips for managing GSM alongside estriol

Use a non-hormonal vaginal moisturiser (such as Replens, Regelle or Yes VM) 2 to 3 times per week for additional hydration between estriol applications.

Use a water-based or silicone-based lubricant during sexual activity if needed.

Avoid soap, bubble bath, perfumed products and douching in the genital area, as these disrupt the vaginal pH and worsen dryness.

Wear cotton underwear and avoid tight-fitting synthetic clothing. Stay sexually active if comfortable, as regular sexual activity (including masturbation) promotes vaginal blood flow and helps maintain tissue health.

Pelvic floor exercises (Kegel exercises) can improve urinary symptoms and sexual function.

When to seek further advice

See your GP if symptoms do not improve after 12 weeks of consistent use, if you develop new or worsening symptoms, if you experience unexpected vaginal bleeding, or if you have concerns about using oestrogen.

Alternative treatments and specialist referral (to a menopause clinic or urogynaecologist) are available for women who do not respond to first-line therapy or who have complex medical histories.

Report any suspected adverse reactions to the MHRA via the Yellow Card scheme at yellowcard.mhra.gov.uk .

Sources

• Ovestin Cream, Summary of Product Characteristics (EMC)
• Estriol, British National Formulary (BNF)
• NICE NG23: Menopause: diagnosis and management
• British Menopause Society
• Vaginal dryness, NHS
• MHRA Yellow Card Scheme