From the Guidelines
Topical estradiol intravaginal creams are a highly effective treatment for vaginal atrophy and related symptoms of genitourinary syndrome of menopause, as evidenced by the most recent guidelines from the National Comprehensive Cancer Network (NCCN) in 2024 1.
Key Points to Consider
- The NCCN guidelines suggest 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.
- 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.
- The guidelines also note that 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.
Treatment Recommendations
- Common prescription options include Estrace (estradiol) cream 0.01%, typically applied as 2-4g vaginally once daily for 1-2 weeks, then reduced to 1-2g 1-3 times weekly for maintenance therapy.
- Premarin (conjugated estrogens) cream 0.625mg/g is another option, used at similar dosing schedules.
- Patients should use the applicator provided with the medication for accurate dosing and insert the cream at bedtime to maximize retention.
Important Considerations
- While these creams primarily provide local effects, some systemic absorption occurs, so they should be used at the lowest effective dose for the shortest duration needed.
- Women with a history of estrogen-dependent cancers, undiagnosed vaginal bleeding, or thromboembolic disorders should discuss risks with their healthcare provider before using these products.
- The ESO-ESMO 4th international consensus guidelines for breast cancer in young women also suggest that low-dose vaginal hormones may be safe during concurrent use with an aromatase inhibitor, but safety data is limited and follow-up is short 1.
From the Research
Topical Estradiol Intravaginal Creams
- Topical estradiol intravaginal creams are a form of local vaginal estrogen therapy used to treat vulvovaginal atrophy and its associated symptoms, such as vaginal dryness, irritation, and dyspareunia 2, 3, 4, 5, 6.
- These creams are designed to deliver a low dose of estrogen directly to the vaginal tissue, reducing the risks associated with long-term systemic hormone therapy 3, 6.
- Studies have shown that topical estradiol intravaginal creams are effective in improving symptoms of vaginal atrophy, including vaginal dryness, itching, and burning, as well as reducing dyspareunia 4, 5, 6.
- The use of low-dose vaginal estrogens, such as those found in topical estradiol intravaginal creams, has been shown to be safe and effective, with minimal systemic absorption and no significant increase in the risk of endometrial hyperplasia or carcinoma 3, 4, 6.
- Topical estradiol intravaginal creams are one of several treatment options available for vaginal atrophy, including vaginal tablets, rings, and non-hormonal lubricants or moisturizers 2, 4, 5, 6.