From the Guidelines
For a 75-year-old female with genitourinary syndrome of menopause, low-dose vaginal estrogen preparations, such as estradiol vaginal cream (Estrace, 0.01%), vaginal tablets (Vagifem, 10 mcg), or the estradiol vaginal ring (Estring), are the safest topical options to use, as they provide effective symptom relief while minimizing systemic absorption, according to the most recent evidence 1.
Key Considerations
- The minimal systemic absorption with these preparations means they generally don't require progesterone opposition in women with an intact uterus, unlike systemic hormone therapy.
- Before starting treatment, a thorough history and physical examination should be performed to rule out other causes of symptoms, and patients should be informed about proper application techniques to ensure effectiveness and minimize side effects.
- The typical regimen for vaginal cream is a small amount (0.5-1g) applied 1-2 times weekly after an initial loading period; vaginal tablets are usually inserted twice weekly; and the vaginal ring is replaced every 90 days.
Benefits of Low-Dose Vaginal Estrogen
- Restores vaginal tissue integrity
- Improves lubrication
- Normalizes vaginal pH
- Reduces superficial dyspareunia and relieves urogenital symptoms related to vaginal atrophy
Important Notes
- Estrogen-only HRT is not advised in populations with a risk of secondary endometrial cancer, but low-dose vaginal estrogen preparations have minimal systemic absorption, making them a safer option 1.
- A thorough discussion outlining the uncertainty and risks and benefits should be had with the patient, especially in cases with a history of cancer or on endocrine therapy 1.
From the FDA Drug Label
When prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy, topical vaginal products should be considered. The FDA drug label does not answer the question.
From the Research
Topical Vaginal Estrogen for Genitourinary Syndrome of Menopause
The safest type of topical vaginal estrogen for a 75-year-old female with genitourinary syndrome of menopause (GSM) is not explicitly stated in the provided studies. However, the following points can be considered:
- Low-dose vaginal estrogen therapy is the criterion standard for treating GSM and is effective and safe for most patients 2.
- Local estrogen is preferred over the oral route due to its safety and efficacy on all symptoms of GSM during low-dose use 3.
- Vaginal estrogen may improve vulvovaginal dryness, dyspareunia, most bothersome symptom, and treatment satisfaction compared with placebo or no treatment 4.
Considerations for Topical Vaginal Estrogen Use
When considering topical vaginal estrogen use, the following points should be taken into account:
- Caution is suggested for survivors of hormone-sensitive cancers 2.
- Current data on the risk of breast cancer recurrence when administering low-dose local estrogen are reassuring but do not support a conclusion that this treatment is safe 3.
- Non-hormonal regimens are a first-line therapy for women with a history of breast cancer 3.
Alternative Treatment Options
Alternative treatment options for GSM include: