What hormone cream is recommended for vaginal atrophy in a 52-year-old postmenopausal female, non-smoker, with no history of gynecological surgery?

From the Guidelines

For vaginal atrophy in a 52-year-old postmenopausal woman with no smoking history or gynecological surgeries, I recommend a low-dose vaginal estrogen cream such as estradiol 0.01% cream. This recommendation is based on the most recent and highest quality study, which found that vaginal estrogen is the most effective treatment for vaginal dryness leading to sexual dysfunction and has been shown to be effective in treating itching, discomfort, and painful intercourse in postmenopausal individuals 1.

Key Points to Consider

• Vaginal estrogen works primarily locally with minimal systemic absorption, making it safer than oral hormone therapy 1.
• A study in 76 postmenopausal survivors of hormone receptor (HR)–positive breast cancer receiving aromatase inhibitor (AI) therapy found that intravaginal testosterone cream or an estradiol-releasing vaginal ring were safe and improved vaginal atrophy and sexual function 1.
• A large cohort study of almost 50,000 patients with breast cancer followed for up to 20 years showed no evidence that there was a higher risk of breast cancer–specific mortality in those using vaginal estrogen 1.

Application and Dosage

Apply a small amount (typically 0.5-1g) of the estradiol 0.01% cream into the vagina daily for 1-2 weeks initially, then reduce to twice weekly maintenance therapy. Before starting treatment, a gynecological examination is recommended to confirm the diagnosis and rule out other conditions. You should notice improvement within 2-4 weeks of consistent use. If you experience unusual bleeding, contact your healthcare provider immediately.

Alternative Options

For women with a history of breast cancer or other estrogen-sensitive conditions, non-hormonal options like moisturizers or lubricants may be more appropriate. Ospemifene, an FDA-approved selective estrogen receptor modulator (SERM), has been studied in several large trials of individuals with postmenopausal vulvar and vaginal atrophy and was found to effectively treat vaginal dryness and dyspareunia, but data in the survivor population are very limited 1.

From the FDA Drug Label

For treatment of moderate to severe vasomotor symptoms, vulvar and vaginal atrophy associated with the menopause, the lowest dose and regimen that will control symptoms should be chosen and medication should be discontinued as promptly as possible. The answer is Estradiol cream for vaginal atrophy, however the provided label is for an Estradiol valerate injection.

• The label does not provide information on a cream formulation.
• The patient should be started at the lowest dose for the indication, but the label does not specify the dose for a cream formulation. 2

From the Research

Treatment Options for Vaginal Atrophy

The user is a 52-year-old postmenopausal non-smoker who has never had gynecological surgery and is experiencing vaginal atrophy. Based on the provided studies, the following treatment options are available:

• Estradiol vaginal cream 0.003% applied twice per week 3
• Topical vaginal treatment with estrogen, testosterone, or polyacrylic acid 4
• Continuous low dose estradiol released from a vaginal ring or estriol vaginal cream 5
• Sustained-release estradiol vaginal tablet (Vagifem) or vaginal estrogen cream 6
• Ultra-low dose 0.005% estriol vaginal gel 7

Key Findings

Some key findings from the studies include:

• Estradiol vaginal cream 0.003% was found to be an effective and well-tolerated treatment for vaginal atrophy symptoms and dryness associated with menopause 3
• Topical estrogen and testosterone were found to improve vaginal trophism in postmenopausal women with vaginal atrophy 4
• Continuous low dose estradiol released from a vaginal ring was found to be equivalent to estriol vaginal cream in improving symptoms of vaginal dryness and signs of vaginal atrophy 5
• Vagifem was found to be as effective as vaginal estrogen creams and more user-friendly in the treatment of atrophic vaginitis 6
• Ultra-low dose 0.005% estriol vaginal gel was found to be effective in improving symptoms and signs of vulvovaginal atrophy in postmenopausal women with early breast cancer treated with nonsteroidal aromatase inhibitors 7

Comparison of Treatment Options

A comparison of the treatment options shows that:

• Estradiol vaginal cream 0.003% and Vagifem are both effective in treating vaginal atrophy symptoms and dryness associated with menopause 3, 6
• Topical estrogen and testosterone may be effective in improving vaginal trophism in postmenopausal women with vaginal atrophy, but may not be as effective as estradiol vaginal cream 0.003% or Vagifem 4
• Continuous low dose estradiol released from a vaginal ring may be equivalent to estriol vaginal cream in improving symptoms of vaginal dryness and signs of vaginal atrophy, but may not be as user-friendly as Vagifem 5
• Ultra-low dose 0.005% estriol vaginal gel may be effective in improving symptoms and signs of vulvovaginal atrophy in postmenopausal women with early breast cancer treated with nonsteroidal aromatase inhibitors, but may not be as effective as estradiol vaginal cream 0.003% or Vagifem 7