Alternative Treatments for Patients Previously Using Estradiol Cream
For patients previously using estradiol cream for vaginal symptoms, vaginal moisturizers and lubricants should be used as first-line therapy, followed by vaginal DHEA (prasterone) or ospemifene if non-hormonal options are insufficient. 1, 2
First-Line Non-Hormonal Options
- Vaginal moisturizers should be applied frequently (3-5 times weekly) for daily comfort in the vagina, at the vaginal opening, and on external vulvar folds 3, 2
- Water-based or silicone-based lubricants should be used during sexual activity to reduce friction and discomfort 3, 2
- Non-hormonal options should be tried thoroughly before considering hormonal alternatives 3
- These options provide temporary relief but may be less effective than topical estrogens for persistent symptoms 3
Alternative Hormonal Options
- Vaginal DHEA (prasterone) is an effective option for women with vaginal atrophy symptoms and can be used even in patients with a history of breast cancer on aromatase inhibitors 1, 3
- Ospemifene, a selective estrogen receptor modulator, can be offered to postmenopausal women without current or history of breast cancer who are experiencing dyspareunia and vaginal atrophy 1, 2
- Low-dose vaginal estradiol tablets (such as 10-μg estradiol-releasing intravaginal tablet) may be considered if available 1
- Transdermal estradiol patches or gels can be considered as they deliver estradiol in a constant manner and produce more physiologic estrone and estradiol levels than oral therapy 4, 5
Special Considerations for Breast Cancer Patients
- For women with hormone-positive breast cancer who are symptomatic and not responding to conservative measures, low-dose vaginal estrogen can be considered after a thorough discussion of risks and benefits 1, 3
- For patients on aromatase inhibitors, vaginal DHEA is preferred over estradiol-containing preparations to avoid potential interference with AI efficacy 3
- Lidocaine can be offered for persistent introital pain and dyspareunia in breast cancer patients 1, 3
Additional Supportive Measures
- Vaginal dilators may benefit patients with vaginismus or vaginal stenosis, particularly important for those treated with pelvic radiation therapy 1, 3
- Cognitive behavioral therapy and pelvic floor exercises may help decrease anxiety, discomfort, and lower urinary tract symptoms 1, 3
- Pelvic floor physiotherapy should be offered to women with pain or other pelvic floor issues 1
Contraceptive Considerations
- For women requiring contraception, non-hormonal methods such as copper IUDs should be considered 1
- Levonorgestrel-releasing IUDs may be appropriate for some patients, providing both contraception and potential relief of vaginal symptoms 1
- Women with positive antiphospholipid antibodies should avoid estrogen-containing contraceptives due to increased thrombosis risk 1
Dosing and Administration
- Recent clinical trials have demonstrated efficacy of very low-dose estradiol vaginal cream (0.003%) applied twice weekly for VVA symptoms 6, 7
- Vaginal rings delivering estradiol can provide more constant plasma concentrations than creams 8
- Daily estradiol doses of 0.2 mg or less are effective in reducing menopausal symptoms 8
Remember that treatment should prioritize safety while effectively managing symptoms, with special attention to any underlying conditions that might contraindicate certain therapies.