From the Guidelines
Women with a history of stroke can use topical estrogen creams as they are not associated with an increased risk of stroke. According to the 2024 guideline for the primary prevention of stroke from the American Heart Association/American Stroke Association 1, topical estrogen treatments are not linked to stroke risk. This is in contrast to oral hormone therapy, which has been associated with an increased risk of cardiovascular disease in multiple randomized controlled trials and meta-analyses 1.
When considering the use of topical estrogen creams in women with a history of stroke, it is essential to evaluate the individual benefits and risks, including the severity of menopausal symptoms and other cardiovascular risk factors 1. Low-dose topical estrogen preparations can be used to manage localized symptoms like vaginal dryness or atrophy, and they should be used at the lowest effective dose for the shortest duration necessary to manage symptoms.
Some key points to consider when using topical estrogen creams in women with a history of stroke include:
- Using the lowest effective dose for the shortest duration necessary to manage symptoms
- Evaluating the individual benefits and risks, including the severity of menopausal symptoms and other cardiovascular risk factors
- Considering non-hormonal alternatives like moisturizers and lubricants as first-line options before initiating topical estrogen therapy
- Regular follow-up appointments to monitor for any adverse effects. The minimal systemic absorption of topical estrogen creams results in lower circulating estrogen levels, potentially reducing the impact on clotting factors and inflammatory markers that could increase stroke risk 1.
From the FDA Drug Label
Estradiol vaginal cream USP 0.01% should not be used in women with any of the following conditions: ... Active arterial thromboembolic disease (for example, stroke, MI) or a history of these conditions.
The use of topical estrogen creams is contraindicated in women with a history of stroke, as it may increase the risk of another stroke or other arterial thromboembolic events 2. Topical estrogen creams should not be used in women with a history of stroke.
From the Research
Guidelines for Topical Estrogen Creams in Women with a History of Stroke
- The use of topical estrogen creams in women with a history of stroke is a complex issue, and the guidelines are not straightforward 3, 4, 5, 6.
- Studies have shown that estrogen replacement therapy may increase the risk of stroke in postmenopausal women, particularly in those with a history of cerebrovascular disease 3, 4.
- However, some studies suggest that lower doses of transdermal estradiol (≤50 μg/day) may not alter stroke risk, and vaginal estrogen may even be associated with a decreased risk of stroke 4, 6.
- The route of administration is also an important factor, with oral hormone therapies being associated with an increased risk of stroke, while transdermal application may not be associated with this risk 6.
- It is essential to weigh the benefits and risks of topical estrogen creams in women with a history of stroke and to consider alternative treatments, such as vaginal moisturizers and lubricants, which can ease symptoms of vulvovaginal atrophy without the potential risks associated with estrogen replacement therapy 7.
Key Considerations
- Women with a history of stroke should be carefully evaluated before starting topical estrogen creams, and the decision to use these creams should be made on an individual basis, taking into account the woman's overall health and medical history 3, 4, 5, 6.
- The dosage and route of administration of estrogen creams should be carefully considered, with lower doses and transdermal application being preferred options 4, 6.
- Alternative treatments, such as vaginal moisturizers and lubricants, should be considered for women with a history of stroke who are experiencing symptoms of vulvovaginal atrophy 7.