From the Guidelines
For postmenopausal women without a uterus who have atrophic vaginitis, low-dose vaginal estrogen therapy is the recommended first-line treatment, as it has been shown to be effective in relieving symptoms with minimal systemic absorption 1. The most effective options include estradiol vaginal tablets (10 mcg inserted vaginally daily for 2 weeks, then twice weekly), estradiol vaginal rings (releasing 7.5 mcg/day, replaced every 90 days), or estrogen vaginal creams (0.5-1 g of conjugated estrogen cream or 0.5-1 g of estradiol cream applied vaginally 1-3 times weekly) 1. Some key points to consider when using vaginal estrogen therapy:
- Treatment should begin with a higher frequency of application for 2-3 weeks to achieve initial relief, then reduce to a maintenance schedule.
- Symptoms typically improve within 1-3 weeks, but treatment should continue long-term as symptoms often recur when therapy is discontinued.
- Vaginal moisturizers and lubricants can be used as adjuncts to enhance the effectiveness of treatment.
- Local estrogen therapy works by restoring vaginal epithelial thickness, increasing blood flow, lowering vaginal pH, and improving the vaginal microbiome, effectively reversing the atrophic changes caused by estrogen deficiency. It's also important to note that, according to the most recent guidelines, vaginal estrogen is safe and effective for postmenopausal women without a uterus, even for those with a history of hormone receptor-positive breast cancer, as a large cohort study showed no evidence of increased breast cancer-specific mortality with vaginal estrogen use 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 usual dosage is 10 to 20 mg Estradiol valerate injection, USP every four weeks When prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy, topical vaginal products should be considered.
The recommended estrogen option for treating atrophic vaginitis in postmenopausal women without a uterus is Estradiol valerate injection, USP. The usual dosage is 10 to 20 mg every four weeks. However, it is also suggested to consider topical vaginal products for the treatment of symptoms of vulvar and vaginal atrophy 2 2.
From the Research
Estrogen Options for Atrophic Vaginitis
For postmenopausal women without a uterus, several estrogen options are available for treating atrophic vaginitis. These options include:
- Vaginal tablets: 17beta-estradiol vaginal tablets, 0.025 mg, applied once daily for two weeks, then twice a week for 22 weeks 3
- Vaginal creams: Conjugated estrogens cream, low-dose regimen, for the treatment of moderate-to-severe postmenopausal dyspareunia 4
- Vaginal rings: Minimally absorbed local vaginal estrogens, recommended as first-line pharmacologic treatment by the North American Menopause and International Menopause Societies 5
Common Dosing Instructions
The dosing instructions for these estrogen options vary:
- 17beta-estradiol vaginal tablets: one application per day for two weeks, then one application twice a week for 22 weeks 3
- Conjugated estrogens cream: low-dose regimen, specific dosing instructions not provided in the study 4
- Vaginal rings: dosing instructions not specified in the studies, but recommended as a minimally absorbed local vaginal estrogen option 5
Safety and Efficacy
The safety and efficacy of these estrogen options have been evaluated in randomized controlled clinical trials:
- 17beta-estradiol vaginal tablets: shown to be effective in treating postmenopausal atrophic vaginitis with minimal incidence of adverse reactions 3
- Vaginal creams and rings: recommended as safe and effective options for treating atrophic vaginitis, with minimal absorption and risk of endometrial proliferation 5, 4, 6