Is vaginal estrogen therapy suitable for a patient with chronic hypertension (CHTN), stage 3 chronic kidney disease (CKD3), and type 2 diabetes mellitus (DM2)?

From the Guidelines

Vaginal estrogen therapy can be safely used in patients with controlled hypertension (CHTN), stage 3 chronic kidney disease (CKD3), and type 2 diabetes mellitus (DM2), but it is crucial to use low-dose preparations to minimize systemic absorption and potential adverse effects.

Key Considerations

• Low-dose vaginal estrogen preparations such as Estrace vaginal cream (0.01%, 0.5-1g applied vaginally 1-3 times weekly), Vagifem tablets (10mcg inserted vaginally twice weekly), or Estring vaginal ring (7.5mcg/24hrs, replaced every 90 days) are recommended options 1.
• These preparations provide localized estrogen therapy with minimal systemic absorption, making them safer choices for patients with comorbidities.
• The minimal systemic absorption means these preparations are less likely to affect blood pressure control, kidney function, or glycemic control compared to oral or transdermal estrogen.
• Vaginal estrogen primarily treats local symptoms like vaginal dryness, irritation, and recurrent urinary tract infections by restoring vaginal tissue integrity.
• Regular monitoring of blood pressure, kidney function, and blood glucose levels is still advised, though significant adverse effects on these parameters are uncommon with vaginal preparations 1.
• Patients should report any unusual symptoms such as vaginal bleeding, severe headaches, or chest pain promptly.

Dosing Considerations

• For patients with CKD, doses of estrogen replacement that are 50%-70% lower than those among women with normal renal function may have an equivalent effect 1.
• Measurement of estradiol levels (and possibly FSH levels) may be of value in selected postmenopausal women with CKD receiving hormone replacement therapy (HRT) 1.

From the FDA Drug Label

1. Fluid retention Because estrogens may cause some degree of fluid retention, patients with conditions that might be influenced by this factor, such as a cardiac or renal dysfunction, warrant careful observation when estrogens are prescribed.
2. Exacerbation of other conditions Estrogens may cause an exacerbation of asthma, diabetes mellitus, epilepsy, migraine or porphyria, systemic lupus erythematosus, and hepatic hemangiomas and should be used with caution in women with these conditions.

• Key considerations:
  • The patient has chronic kidney disease (CKD) stage 3, which may be affected by the potential for fluid retention caused by estrogens.
  • The patient has type 2 diabetes mellitus (DM2), which may be exacerbated by estrogen therapy.
  • The patient has chronic hypertension (CHTN), and while there is a mention of potential increases in blood pressure due to idiosyncratic reactions to estrogens, the overall risk needs to be weighed against the benefits.
• Clinical decision: Vaginal estrogen therapy may not be entirely suitable for this patient due to the potential for exacerbating diabetes mellitus and the need for careful observation due to renal dysfunction. Additionally, the potential impact on blood pressure should be closely monitored. Given these considerations, caution is advised, and the decision to use vaginal estrogen therapy should be made on a case-by-case basis, considering the individual's overall health status and under close medical supervision 2.

From the Research

Patient Conditions

• Chronic hypertension (CHTN)
• Stage 3 chronic kidney disease (CKD3)
• Type 2 diabetes mellitus (DM2)

Vaginal Estrogen Therapy

• Vaginal estrogen therapy may be beneficial for patients with CKD3, as estrogens have a protective effect on the kidneys, attenuating glomerulosclerosis and tubulo-interstitial fibrosis 3
• The use of low-dose vaginal estrogens has been shown to be effective in treating symptoms of vaginal atrophy without causing significant proliferation of the endometrial lining 4
• Ultra-low-dose vaginal estrogen tablets have minimal estradiol absorption and provide significant symptom relief for postmenopausal women with vaginal atrophy 5

Considerations

• Patients with CHTN, CKD3, and DM2 should be carefully evaluated for the use of vaginal estrogen therapy, considering the potential risks and benefits 3, 4
• The lowest effective dose of vaginal estrogen therapy should be used to minimize potential risks 6, 5
• Patients should be informed of the potential benefits and risks of treatment options and choose an intervention that is most suitable to their individual needs and circumstances 4

Treatment Options

• Vaginal estrogen therapy, including ultra-low-dose vaginal estrogen tablets and low-dose vaginal estrogen creams or rings, may be suitable for patients with CHTN, CKD3, and DM2 3, 5, 4, 7
• Selective estrogen receptor modulators (SERMs) may also be considered as an alternative to vaginal or systemic estrogen therapy, but their use should be carefully evaluated in patients with CHTN, CKD3, and DM2 6