From the Guidelines
For vaginal estrogen therapy, I recommend starting with low-dose vaginal estradiol in the form of Vagifem (estradiol vaginal tablets 10 mcg) inserted vaginally once daily for 2 weeks, then twice weekly for maintenance, as it is the most effective treatment for vaginal dryness and has minimal systemic absorption 1. When considering vaginal estrogen therapy, it's essential to weigh the benefits and risks, particularly for patients with a history of estrogen-sensitive cancers.
- Vagifem, Estring, and Estrace vaginal cream are effective options for treating vaginal atrophy, with minimal systemic absorption 1.
- The choice between formulations depends on patient preference, with tablets and rings offering less messiness and precise dosing compared to creams, though creams may provide better coverage for the vulva if needed.
- For patients with a history of estrogen-sensitive cancers, it's crucial to discuss with their oncologist first, as vaginal DHEA (Intrarosa) or ospemifene (Osphena) might be safer alternatives in some cases 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.
- Vaginal estrogen therapy has been shown to be effective in treating itching, discomfort, and painful intercourse in postmenopausal individuals, with minimal systemic risks associated with its use 1.
From the FDA Drug Label
When estrogen is prescribed for a postmenopausal woman with a uterus, progestin should also be initiated to reduce the risk of endometrial cancer. Patients should be started at the lowest dose for the indication The lowest effective dose of Estradiol valerate injection, USP has not been determined for any indication.
The FDA drug label does not answer the question.
From the Research
Vaginal Estrogen Options
- The choice of vaginal estrogen to start depends on various factors, including the severity of symptoms, patient preferences, and medical history 2, 3, 4, 5.
- Low-dose vaginal estrogen therapies are effective and safe for relieving symptoms of vaginal atrophy, with benefits including sustained relief of symptoms and physiological improvements 2, 4, 5.
- Currently available local vaginal estrogen therapies are well tolerated and effective in relieving symptoms of vaginal atrophy, with no significant difference observed between various dosages and dosage forms of vaginal estrogen products 3, 5.
Types of Vaginal Estrogen
- Estrogen creams, inserts, and rings are available, with newer low-dose estradiol rings, tablets, and inserts appearing to induce the least increases in serum hormones, possibly indicating greater safety 3.
- Conjugated estrogens/bazedoxifene (CE/BZA) and estrogen/progestin combination hormone therapy (EP) are also options, with CE/BZA users potentially experiencing slightly higher rates of endometrial cancer and endometrial hyperplasia, and a lower rate of breast cancer, than EP users 6.
Safety Considerations
- The endometrial safety of low-dose vaginal estrogens has been supported by several studies, with no increased risk of endometrial hyperplasia or cancer observed 2, 4, 5.
- However, longer-term, real-world data are needed to fully assess the safety of vaginal estrogen use, particularly with regards to endometrial cancer and breast cancer risk 3, 4, 6.