Is it safe to continue using an E2/estriol/prog cream in a patient with suspected buried labial and vaginal tissues, endogenous E2 production, and a complex reproductive anatomy?

From the Guidelines

I would not recommend continuing the E2/estriol/progesterone cream in a patient with suspected buried labial and vaginal tissues, endogenous estradiol production, and complex reproductive anatomy without specialist evaluation. This situation requires assessment by a gynecologist or reproductive endocrinologist before continuing hormone therapy. The presence of buried genital tissues combined with endogenous estrogen production creates a complex clinical picture where additional exogenous hormones may potentially cause unpredictable effects.

The patient should temporarily discontinue the cream and seek prompt evaluation to determine the exact anatomical configuration, current hormone levels, and appropriate treatment plan. The specialist may recommend imaging studies, hormone level testing, and possibly examination under anesthesia to fully understand the anatomy. The concern is that continued use of topical hormones without proper assessment could potentially stimulate abnormal tissue growth, cause hormonal imbalances, or mask symptoms that might indicate a more serious underlying condition requiring different management.

Some key considerations in managing such patients include the potential benefits and risks of hormone replacement therapy, as discussed in the context of gynecologic cancer survivors 1. However, the specific scenario of suspected buried labial and vaginal tissues, along with endogenous estrogen production and complex reproductive anatomy, necessitates a cautious approach. The use of vaginal estrogens or other topical therapies may be considered under the guidance of a specialist, taking into account the individual's overall health status, the nature of their reproductive anatomy, and their specific symptoms or conditions, such as vaginal dryness or pain during sexual intercourse 1.

Given the complexity of this case and the potential for significant morbidity or mortality associated with inappropriate management, a thorough evaluation by a specialist is essential. This evaluation should consider all relevant factors, including the patient's medical history, current symptoms, and the results of any diagnostic tests, to determine the safest and most effective course of treatment. The goal of management should be to optimize the patient's quality of life while minimizing the risk of adverse outcomes.

In terms of specific management strategies, the patient may benefit from a multidisciplinary approach that includes gynecologic care, possibly involving the use of vaginal dilators, topical therapies, or other interventions aimed at managing symptoms and preventing complications such as vaginal stenosis 1. However, any treatment plan should be tailored to the individual's unique needs and circumstances, taking into account the latest evidence and guidelines in the field 1.

From the Research

Safety of E2/Estriol/Prog Cream in Patients with Suspected Buried Labial and Vaginal Tissues

• The patient's condition, with suspected buried labial and vaginal tissues, endogenous E2 production, and a complex reproductive anatomy, requires careful consideration when using hormone replacement therapy (HRT) 2, 3.
• Bioidentical hormones, such as estradiol, estriol, and progesterone, have been shown to have a potentially better safety profile compared to synthetic hormones 4.
• A study on compounded bioidentical transdermal hormone therapy, including estriol, estradiol, and progesterone, found significant favorable changes in menopausal symptoms, cardiovascular biomarkers, and health outcomes in peri/postmenopausal women 5.
• However, it is essential to note that the patient's specific condition and the use of an E2/estriol/prog cream may require individualized consideration, and the current evidence may not directly address this specific scenario.

Considerations for Transdermal Estrogen Therapy

• Transdermal estrogen therapy has been shown to confer little to no increased risk of venous thromboembolism (VTE) compared to oral estrogen therapy 6.
• The use of bioidentical hormones, such as estriol and progesterone, in combination with estradiol, may offer a different risk/benefit profile compared to synthetic hormones 4.
• A study on the effects of compounded bioidentical transdermal hormone therapy found that the therapy did not adversely alter the net prothrombotic potential and did not have any associated adverse events 5.

Individualized Approach

• Given the patient's unique condition and the lack of direct evidence addressing the use of an E2/estriol/prog cream in this specific scenario, an individualized approach is necessary 2, 3.
• Close monitoring of the patient's response to the therapy and adjustment of the treatment regimen as needed is crucial to ensure the safe and effective use of the E2/estriol/prog cream.