From the Guidelines
The recommended frequency for using vaginal estrogen to treat vaginal atrophy typically involves an initial intensive phase followed by a maintenance regimen, with most products applied daily for the first 1-2 weeks, then reduced to 2-3 times per week, as supported by the most recent guidelines 1.
Key Considerations
- 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.
- The initial higher frequency helps to restore vaginal tissues quickly, while the maintenance dose prevents symptoms from returning.
- Specific products have their own dosing schedules: vaginal creams are usually inserted 1 gram daily for 1-2 weeks then 1-3 times weekly; vaginal tablets are inserted daily for 2 weeks then twice weekly; and vaginal rings are inserted and left in place for 90 days before replacement.
Important Details
- Vaginal estrogen works by increasing blood flow to vaginal tissues, improving lubrication, and restoring normal vaginal pH and thickness.
- Most women notice improvement within 4-6 weeks of starting treatment, though some symptoms may improve sooner.
- Treatment typically continues long-term as symptoms often return when therapy is discontinued.
- 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.
Product-Specific Guidance
- Vaginal creams (like Premarin or Estrace) are usually inserted 1 gram daily for 1-2 weeks then 1-3 times weekly.
- Vaginal tablets (like Vagifem) are inserted daily for 2 weeks then twice weekly.
- Vaginal rings (like Estring) are inserted and left in place for 90 days before replacement.
Safety and Efficacy
- The safety of vaginal hormones has not been firmly established in survivors of estrogen-dependent cancers, and their use should be approached with caution 1.
- Vaginal estrogens can be administered in the form of an estradiol-releasing vaginal ring, estrogen-based vaginal creams, pessaries containing estriol, and a slow-release 17b estradiol tablet 1.
From the Research
Recommended Frequency for Vaginal Estrogen Therapy
The recommended frequency for using vaginal estrogen to treat vaginal atrophy is not explicitly stated in terms of a specific number of times per week or month. However, the following points can be considered:
- Vaginal estrogen therapy can be used as long as distressful symptoms remain, according to the North American Menopause Society 2.
- Low-dose vaginal estrogen products are equally effective at the doses recommended in labeling, and the choice of therapy should be guided by clinical experience and patient preference 2.
- Treatment regimens with 25-μg 17β-estradiol vaginal tablets have been shown to be effective in relieving symptoms of atrophic vaginitis, with a localized effect without appreciable systemic estradiol increases or estrogenic side effects 3.
- Topical vaginal treatment with estrogen, three times a week for 12 weeks, has been shown to improve vaginal health score, vaginal flora, and vaginal maturation index in postmenopausal women with vaginal atrophy 4.
Key Considerations
- The North American Menopause Society recommends that vaginal estrogen therapy should be continued for women as long as distressful symptoms remain 2.
- Progestogen is generally not indicated when low-dose estrogen is administered locally for vaginal atrophy 5, 2.
- Data are insufficient to recommend annual endometrial surveillance in asymptomatic women using vaginal estrogen therapy 2.
- Vaginal estrogen therapy has been shown to be effective and well-tolerated for treating vaginal atrophy, with benefits including sustained relief of symptoms and physiological improvements 6, 5, 3, 4.