VAGINAL & VULVAL COMFORT
Dryness, burning, soreness or pain with sex can affect everyday comfort and intimacy. Menopausal tissue changes may contribute, but similar symptoms can have other causes. We work out what is happening and choose treatment that fits you.
UNDERSTANDING GSM
Genitourinary syndrome of menopause (GSM) describes symptoms and tissue changes linked to declining sex hormones around and after menopause. The vulva is the external genital skin; the vagina is the passage inside. The urine opening and nearby tissues can be affected too.
Tissues may become drier, less elastic and more easily irritated by friction, urine or products. The vaginal environment and bacterial balance can change. Symptoms may affect walking, exercise, clothing or washing as well as sex.
Penetration may sting, feel tight or cause a tearing sensation. Anticipating pain can lead to muscle guarding. You do not need to be sexually active to benefit from treatment, and you should not push through painful penetration.
Stinging, urgency and frequent urination may accompany GSM. It can also contribute to recurrent urinary infections. Infection, overactive bladder and bladder pain can coexist, so urinary symptoms still need their own assessment.
Symptoms may develop during perimenopause or after removal or suppression of the ovaries. Similar low-oestrogen changes can occur during breastfeeding or with some medicines. In younger women we consider the cause and the exact treatment carefully; a menopause product is not automatically suitable for every situation.
GSM often persists without treatment. Improvement and ongoing comfort are realistic aims, although more than one treatment may be needed.
GETTING THE CAUSE RIGHT
The location, timing and appearance of symptoms matter. Repeatedly changing antifungals, antibiotics or hormone creams without reviewing the diagnosis can delay the right care.
Thrush, bacterial vaginosis and some sexually transmitted infections can cause overlapping symptoms. Scented washes, wipes, pads, detergents or a treatment itself may irritate the skin. Discharge or a new odour may call for examination and selected swabs.
Pain that increases as the bladder fills, difficulty emptying, prolapse or persistent urgency needs a broader review. Tender, overactive pelvic-floor muscles can keep sex painful even after dryness improves. Treatment may involve relaxation and physiotherapy rather than more strengthening exercises.
LICHEN SCLEROSUS & VIN
GSM, inflammatory skin conditions and precancerous changes can share symptoms. They can also occur together. Improvement in dryness does not explain every remaining patch, sore or area of pain.
Lichen sclerosus is an inflammatory skin condition. It can cause itching, splitting, pale or white areas, bruising, scarring and changes in the shape of the vulva. It is not simply a consequence of low oestrogen and usually affects the external skin rather than the inside of the vagina.
Oestrogen does not treat lichen sclerosus itself. A prescribed potent steroid ointment, skin care and ongoing review are usually needed. Local oestrogen may help coexisting GSM, so both treatments may have a role. Their application sites and schedules should be explained separately.
Some cases can be diagnosed clinically. Biopsy may help if the diagnosis is uncertain, treatment is not working as expected or a particular area looks concerning. Continuing review matters because scarring and, in a minority of women, vulval cancer can occur.
Vulval intraepithelial neoplasia (VIN) means abnormal cells in the surface skin that can progress to cancer. It is different from invasive cancer and from GSM. HPV-associated disease is often called vulval HSIL. Another form, differentiated VIN, is usually unrelated to HPV and can develop alongside lichen sclerosus.
VIN can be subtle. A persistent thickened or rough patch, sore, changing colour or focal irritation deserves examination. A suspicious area needs a biopsy to establish the diagnosis and check for invasion; its appearance or response to a cream cannot reliably settle this.
Treatment and follow-up depend on the type. Differentiated VIN generally needs excision; some HPV-associated lesions have other treatment options. A normal cervical smear or HPV screening result does not rule out a vulval lesion.
A new lump, non-healing ulcer, repeated split in the same place, focal bleeding or a patch that changes despite treatment should be checked. Most vulval discomfort has a non-cancerous explanation, but persistent changes should not be repeatedly labelled as thrush or dryness without examination. Lichen planus, eczema and other skin disorders may also need specific care.
Clinical context: ISSVD lichen sclerosus guide · lichen sclerosus and menopausal changes · specialist consensus on VIN.
YOUR CONSULTATION
Tell me where it hurts or itches, when it began, any urinary symptoms or bleeding, and what you have tried. Medicines, products, menopause timing, cancer treatment and your priorities all help. Bring packs or photographs of previous treatments if available.
Looking at the external skin may be particularly helpful. An internal examination is discussed when it can answer a useful question. We explain each step, adapt for discomfort and can pause or stop. You can ask about a chaperone.
GSM is usually a clinical diagnosis. Urine testing or cultures, swabs, a bladder scan or a skin biopsy are used for specific concerns. Vaginal acidity may support the assessment but does not diagnose the cause alone. Routine hormone panels or microbiome tests are not needed to choose GSM treatment.
We agree what improvement would mean for you and when to review. You do not need to arrange tests or decide which treatment you want before booking.
Back to contents ↑WHAT CAN HELP
Everyday comfort, local tissue treatment and care for another diagnosis can work together. You do not have to progress through a fixed ladder of products.
Moisturisers support day-to-day comfort. Lubricants reduce friction during sexual activity or insertion.
Local vaginal oestrogen can improve dryness and fragility and help some urinary symptoms.
A steroid ointment treats inflammation in lichen sclerosus. It has a different role from oestrogen.
These are simplified illustrations of treatment roles, not application or dose instructions.
Avoid douching, fragranced washes and repeated cleansing. Wash the external skin gently and avoid products that sting. A vaginal moisturiser is used regularly according to its instructions; a lubricant is used when friction is expected. Choose products made for the intended area.
Water- or silicone-based lubricants can help; check compatibility with condoms and sex toys. Oils and some cream bases can damage latex. Hyaluronic-acid moisturisers are one option, but no single product suits everyone. Stop a product that persistently irritates and seek advice.
Low-dose vaginal oestrogen has an established role for bothersome GSM. It can be used with moisturisers or lubricants, and sometimes alongside systemic HRT. It does not treat hot flushes or provide the bone protection of systemic treatment.
For recurrent UTIs associated with menopause, it can reduce future infections; it does not treat an active UTI. Pain may also need pelvic-floor physiotherapy, time for comfortable arousal, changes in sexual activity or carefully guided dilators. Dilators should not be forced through pain.
CHOOSING A PREPARATION
The ingredient, strength, formulation and dose all matter. Symptoms, comfort, dexterity, tolerance and access help us choose. These examples describe South African product information; your prescription and the leaflet supplied with your own product guide its use.
| Option | Form & application | What to check |
|---|---|---|
| Gynoflor | Estriol + lactobacilli tablet, inserted with a finger. | Daily initial course, then maintenance. Contains oestrogen. |
| Vagifem 10 | 10 microgram estradiol tablet, single-use applicator. | Daily for two weeks, then twice weekly. Check comfort with insertion. |
| Synapause | Estriol cream, measured reusable applicator. | Short daily course, then reduced frequency. Cream weight is not the hormone dose. |
| Premarin | Conjugated-oestrogen cream, measured applicator. | Individual dose and schedule; the local label describes cyclic use. |
| DHEA or compounded products | Formulations vary; evidence for a standardised pessary does not establish a cream’s effects. | Confirm exact product, indication, local access and review plan. |
A comparison for discussion, not interchangeable prescriptions. The detailed entries below explain strengths, schedules and cautions. More than one hormone product is not automatically needed.
Estriol + lactobacilli
Gynoflor combines 0.03 mg estriol with Lactobacillus acidophilus. Estriol acts on low-oestrogen vaginal tissue; the bacteria form part of the vaginal environment. This is a hormone-containing treatment, not simply a probiotic.
The local instructions describe one tablet daily for at least twelve days, then one tablet on two to three days each week for maintenance. It is inserted into the vagina with a finger, usually in the evening. Follow the leaflet rather than assuming another vaginal tablet has the same schedule.
Burning, itching or discharge can occur. The patient leaflet advises review if symptoms worsen or have not improved after twelve days. This combination does not establish that other probiotics work equally well or that microbiome testing is needed.
Estradiol 10 micrograms
A small vaginal tablet supplied in a single-use applicator. It may suit someone who prefers a measured tablet to a cream, although the applicator must feel comfortable and manageable.
The South African schedule is one tablet daily for two weeks, then one tablet twice weekly. Release the tablet using the applicator as shown in the leaflet; do not force insertion against pain or resistance. Dispose of the used applicator.
Some women still need a separate plan for external skin symptoms. If the entrance remains sore, assess the cause before adding another hormone product. Local discomfort, discharge or spotting should be discussed if persistent; unexplained bleeding needs assessment.
South African Vagifem leaflet · prescribing information, December 2024.
Estriol 1 mg per gram
The marked applicator measures the cream. One application filled to its ring mark contains 0.5 g cream, providing 0.5 mg estriol. The weight of cream and the amount of hormone are different measurements.
For menopausal tissue symptoms, the local information describes one application daily for the first two to three weeks, then a gradual reduction according to relief towards twice-weekly maintenance. This daily phase is a short initial course, not the maintenance schedule. Follow the current leaflet supplied with your pack and do not extend the prescribed course yourself.
Cream may leak or irritate some women. Use and clean the applicator according to its leaflet. If a clinician recommends a small amount on external tissue, ask for the exact site, amount and schedule rather than extending the internal prescription yourself.
SAHPRA-hosted Synapause information, 2014. This is an older accessible label; your pharmacist should confirm the current pack instructions.
Conjugated oestrogens
This manufactured cream contains 0.625 mg conjugated oestrogens per gram. It is a different medicine from estriol cream and from a pharmacy-compounded preparation. The prescribed amount matters; not every cream dose has the same absorption or risk profile.
The South African label describes cyclic, short-term use, with an example of three weeks on and one week off and an individual dose range. It does not share Synapause’s standard maintenance instructions. Ask for a clearly measured dose and written plan; do not copy another cream’s schedule.
Modern guidance supports ongoing low-dose local treatment for persistent GSM when appropriate, while this product’s label has different duration wording. Your prescriber should explain the selected regimen, any use outside the label and how it will be reviewed. Systemic absorption can occur.
Cream allows application to a prescribed area; a tablet delivers a measured vaginal dose. There is no universally best formulation. Persistent external symptoms may need treatment for skin disease, irritation or pain rather than simply adding more oestrogen. Combining preparations should be an agreed plan.
Product information confirms an authorised formulation, not current pharmacy stock. Tell your pharmacist the exact name and strength; substitutions need a suitable prescription and instructions.
DHEA, COMPOUNDING & OTHER OPTIONS
DHEA is a precursor that tissues convert into oestrogens and androgens. Standardised vaginal prasterone, such as the 6.5 mg Intrarosa pessary authorised internationally, has evidence for postmenopausal vaginal symptoms and painful sex. Benefit varies; discharge is a common practical issue.
A compounded DHEA cream is a different preparation. Its concentration, base, application site and absorption may differ. Evidence for the pessary cannot establish that a cream, mixed formula, oral supplement or skin product works in the same way. Do not insert an oral supplement or ordinary skin cream into the vagina.
DHEA is not hormone-free or automatically suitable after hormone-sensitive cancer. The international product information contains contraindications, including breast-cancer history and unexplained bleeding. South African registration, access and the exact preparation must be checked when considering it.
A compounding pharmacy prepares a prescribed formula, which may contain estriol, estradiol, DHEA or a combination. It can sometimes address an ingredient intolerance or a formulation that is unavailable as a suitable manufactured product.
Compounded does not mean automatically safer, more natural or more effective. The finished preparation may not have the same testing for dose consistency, stability, absorption, efficacy and safety as a registered product. South African professional guidance advises against routine compounded hormone treatment when a suitable regulated option exists.
Ask what each ingredient is for, the strength and measured dose, whether it goes inside the vagina or on external skin, storage and expiry, and when to review. Record reactions to the base as well as the active ingredient. Saliva or urine tests do not reliably determine a personalised cream mixture.
Low-dose vaginal rings and oral ospemifene are used internationally. Ospemifene acts on oestrogen receptors and has systemic precautions; it is not equivalent to a vaginal moisturiser. Suitability and South African access need checking before either is presented as an available choice.
I do not offer vaginal laser in my practice. Evidence does not support offering it as routine GSM care; NICE recommends its use only within a randomised controlled trial. Failure of one cream is a reason to review the diagnosis and treatment, rather than automatically move to a procedure.
SAFETY & INDIVIDUAL CIRCUMSTANCES
With recognised low-dose vaginal oestrogen regimens, little hormone reaches the bloodstream and a separate progestogen is usually not needed. This does not apply automatically to higher doses, every cream schedule or a compounded mixture. If you also use systemic oestrogen and have a uterus, its protection requirements still apply.
Routine womb scans or biopsies are not needed solely because someone uses low-dose vaginal oestrogen without symptoms. Unexpected bleeding does need assessment. Review treatment regularly and tell us about new health conditions or medicines.
Begin with non-hormonal options and treatment of other causes of discomfort. If symptoms remain troublesome, selected women may discuss low-dose vaginal oestrogen through shared decision-making. Evidence about recurrence is limited; minimal absorption does not mean zero absorption.
For women taking an aromatase inhibitor, involve the breast-cancer specialist. Tamoxifen and aromatase inhibitors work differently, so the discussion is not identical. After a gynaecological cancer, the type, hormone sensitivity and current treatment matter. DHEA and compounded products are not automatic substitutes.
Some uses supported by specialist guidance differ from product licences, particularly after cancer or before menopause. We should explain that difference, the alternatives and the uncertainty. Do not stop cancer treatment to use a vaginal product.
Guidance: NICE: vaginal symptoms and breast-cancer history · AUA/SUFU/AUGS GSM guideline, 2025.
MAKING TREATMENT MANAGEABLE
Record the exact product, dose, application site and days. Wash your hands before and after use. Check whether an applicator is disposable or reusable. A calendar reminder can help with maintenance days. For a missed dose, follow the product leaflet; do not double up.
Some relief may begin within weeks; fuller benefit can take up to about three months. Symptoms may recur when treatment stops. Review is usually around three months and at least annually thereafter, with earlier review for problems or when the product leaflet advises it.
Allow time for arousal, use a suitable lubricant and choose activities that feel comfortable. Treatment can support intimacy without making penetration a goal. Ask about product timing and condom compatibility; these differ between creams and other preparations.
IF TREATMENT IS NOT GOING TO PLAN
Irritation can come from fragile tissue, the product base, allergy or another diagnosis. Persistent or worsening burning needs review rather than repeated applications or extra products. Stop the suspected irritant and seek advice. Swelling with breathing difficulty needs emergency care.
Do not force it. Narrowing, skin disease, dryness or muscle guarding may contribute. We can assess the cause, review the formulation and discuss a gentler approach. Guided physiotherapy or dilators may help selected women.
Some residue can occur and does not automatically mean the dose failed. Check the leaflet and routine; do not repeat the dose just because material is visible. New odour, blood, marked itching or persistent discharge needs assessment.
Check whether maintenance stopped, doses were missed or a product changed. Bring the actual packs. A recurrence may need a reviewed schedule, a better-tolerated preparation or investigation of another cause; do not keep increasing the dose yourself.
A persistent sore, thickened patch, recurring split or new skin change needs examination for skin disease, VIN or another cause. A response elsewhere to oestrogen does not exclude a separate lesion. Read about lichen sclerosus and VIN ↑.
Pelvic-floor overactivity, vestibular pain, scarring or deeper pelvic pain can remain. Pain-focused assessment and physiotherapy may help. Avoid pushing through pain or assuming the only answer is more hormone treatment.
Urine cultures during symptomatic episodes help distinguish infection from irritation and other bladder conditions. Vaginal oestrogen may reduce recurrence, but an active infection needs its own plan. Fever, flank pain or vomiting calls for urgent assessment.
Report unexplained bleeding, including after sex. It may arise from fragile tissue, but that should not be assumed. Bleeding after menopause needs assessment even if light or only once; severe bleeding or feeling faint needs urgent help.
A FEW REMAINING QUESTIONS
Yes, sometimes. Systemic HRT may help flushes while vaginal or urinary symptoms still need local treatment. The combined plan should account for the exact products and doses. Read the HRT guide.
No. Daily comfort, skin fragility and urinary symptoms are valid reasons to discuss care. Treatment and sexual activity are personal choices; you do not need to attempt penetration to justify treatment.
Breastfeeding can cause low-oestrogen symptoms, but the products have different instructions and evidence in this setting. We first assess the cause and consider non-hormonal care. Any hormonal treatment should be chosen individually with its local product information in mind.
No. Cervical screening checks the cervix. It does not replace examination of a vulval sore, patch or lump, and it cannot rule out lichen sclerosus or VIN. Tell us about a persistent change even when your cervical screening is up to date.
YOUR NEXT STEP
You can bring an existing prescription, previous results or uncertainty about the cause. Consultations are in Claremont, with additional appointments in Simon’s Town on selected Mondays. Reception will confirm your date, time and venue.
General information to support your consultation. Treatment and any use outside a product’s licence need an individual discussion. Page updated: .
Core guidance: NICE menopause guidance · AUA/SUFU/AUGS GSM guideline, 2025 · Vaginal oestrogen: practical overview. Product information and skin-condition sources are linked beside the relevant sections.