by Sara Hover, RPh, FAARM, PCCA Clinical Services Manager

Menopause, defined as the permanent cessation of menstruation (amenorrhea), is a natural part of aging. Perimenopause occurs prior to menopause and is caused by an erratic release of hormones. A woman is not considered menopausal until she experiences 12 consecutive months of amenorrhea.

One of the most common symptoms associated with menopause is genitourinary syndrome of menopause (GSM), more commonly known as vulvovaginal atrophy. GSM can vary from woman to woman and may include vaginal dryness, burning or itching, urinary issues, painful intercourse and decreased libido. These changes, which occur in the vaginal area, are most likely due to a lack of estrogen.¹

Estrogens and the Vaginal Microbiome

Estrogen — in particular estriol — plays an important role in maintaining the health of the vaginal microbiome, which contains microorganisms that normally inhabit the vaginal canal. These microorganisms, mainly lactobacilli, help maintain a healthy pH and protect against infection. The reduction in lactobacilli changes the vaginal environment to an alkaline pH of more than 5. The normal pH of vaginal tissue is 3.5-4.5.²

During menopause, the decrease in estrogen levels can lead to changes in the vaginal microbiome composition. The reduction of lactobacilli and the increase of other microorganisms may cause an imbalance, known as bacterial vaginosis (BV). BV is associated with an increased risk of urinary tract infections and sexually transmitted infections.³

Estrogens and the Vaginal Epithelium

Estrogens also play an important role in maintaining the health of the vaginal epithelium, which is the outer layer of cells that line the vaginal canal. The decrease in estrogen levels during menopause can lead to a thinning of the vaginal epithelium, making it more susceptible to infection and injury. Vaginal supportive tissues demonstrate a 75% decrease in collagen I, the major determinant of tissues’ tensile strength, in menopausal women compared with premenopausal women. Systemic estrogen therapy results in restoration of collagen I levels to the premenopausal state.⁴

Hormone therapy, which includes the use of estrogen in combination with progesterone, can help alleviate the symptoms of GSM. However, it is important to discuss the potential risks and benefits of hormone therapy with a healthcare provider.

The Base Matters

When choosing a compounding base for vaginal hormone therapy, make sure the base is nonirritating and has been tested for the delicate vaginal tissue. Also consider if the base has mucoadhesion properties, such as those in PCCA Ellage® Anhydrous Vaginal (PCCA #30-5110). Ellage offers longer contact times, which means hormones in the preparation adhere to the vaginal tissue longer. In addition, the properties of Ellage may help prevent leakage to a greater degree than bases without mucoadhesion.

Another factor to consider is ensuring hormones are released into the vaginal fluid without affecting the pH of the vagina. As previously mentioned, maintaining an appropriate pH helps support friendly microorganisms. PCCA Science conducted studies that show Ellage is nonirritating and incredibly gentle on mucosal tissue, providing a pleasant base for customized vaginal preparations.

GSM is a common condition that affects many women during menopause and some during perimenopause. The condition can cause discomfort, pain and may lead to an increased risk of infection. Estrogens play an important role in maintaining the health of the vaginal microbiome and epithelium, and hormone therapy can be an effective treatment option for women experiencing GSM symptoms. Consult with the prescribing physician and choose the right base to help women experiencing GSM.

Attention PCCA Members! Get additional information to help hormone therapy patients by signing up for the PCCA HRT Symposium, held in person and virtually, on July 13-15, 2023. Click to register.

References

1. Kim, H. K., Kang, S. Y., Chung, Y. J., et al. (2015). The Recent Review of the Genitourinary Syndrome of Menopause. J Menopausal Med. 21(2), 65–71. Accessed January 2023 at https://DOI.org/10.6118/jmm.2015.21.2.65

2. La Rosa, V. L., Ciebiera, M., Lin, L. T., Fan, S., et al. (2019). Treatment of genitourinary syndrome of menopause: the potential effects of intravaginal ultralow-concentration oestriol and intravaginal dehydroepiandrosterone on quality of life and sexual function. Prz Menopauzalny, 18(2), 116–122. Accessed January 2023 at https://DOI.org/10.5114/pm.2019.86836

3. Achondou, A. E., Fumoloh, F. F., Aseneck, A. C., et al. (2016). Prevalence of Bacterial Vaginosis Among Sexually Active Women Attending the CDC Central Clinic Tiko, South West Region, Cameroon. Afr J Infect Dis. 10(2), 96–101. Accessed January 2023 https://DOI.org/10.21010/ajid.v10i2.4

4. Alperin, M., Burnett, L., Lukacz, E., et al. (2019). The mysteries of menopause and urogynecologic health: clinical and scientific gaps. Menopause. 26(1), 103–111. Accessed January 2023 at https://DOI.org/10.1097/GME.0000000000001209