What is the recommended treatment for vaginal erosion using estrogen (oestrogen) cream?

Treatment of Vaginal Erosion with Oestrogen Cream

For vaginal erosion in postmenopausal women, low-dose vaginal oestrogen cream (0.003% estradiol, 15 μg in 0.5 g cream) applied daily for 2 weeks followed by twice-weekly maintenance is the recommended treatment, as it effectively restores vaginal epithelial thickness and resolves atrophic changes. 1, 2

Understanding the Clinical Context

Vaginal erosion typically occurs in the context of vaginal atrophy, where decreased oestrogen leads to thinning of vaginal epithelium, making tissues fragile and prone to erosion, bleeding, and inflammation. 3, 4 This condition affects up to 60% of postmenopausal women and significantly impacts quality of life. 4

Treatment Algorithm

First-Line Approach: Vaginal Oestrogen Therapy

Recommended dosing regimen:

• Estradiol vaginal cream 0.003% (15 μg estradiol in 0.5 g cream) applied daily for 2 weeks, then twice weekly for maintenance 1, 2
• Alternative formulations include estradiol vaginal tablets 10 μg daily for 2 weeks, then twice weekly 1
• Vaginal oestrogen rings provide sustained release over 3 months and offer superior convenience 1, 5

Why vaginal oestrogen is preferred:

• Directly reverses atrophic changes and increases vaginal epithelial thickness 6, 4
• Minimal systemic absorption with no concerning safety signals regarding stroke, venous thromboembolism, or breast cancer in large studies 1
• Treatment results in symptom relief in 80-90% of patients who complete therapy 3
• More effective than non-hormonal options for treating erosion and atrophic changes 4

When Vaginal Oestrogen Cannot Be Used

Absolute contraindications include: 3

• History of hormone-sensitive cancers (particularly breast cancer)
• Undiagnosed abnormal vaginal bleeding
• Active or recent pregnancy
• Active liver disease

Alternative options if oestrogen is contraindicated:

• Vaginal DHEA (prasterone) - FDA-approved for vaginal atrophy and may be used in women on aromatase inhibitors 3, 7
• Non-hormonal vaginal moisturizers (Replens, Sylk) used 3-5 times weekly for maintenance 7
• Hyaluronic acid preparations to reduce mucosal inflammation and promote healing 3, 7

Important Clinical Considerations

For Women Without a Uterus

Oestrogen-only therapy is specifically recommended and does not require progestogen addition, providing a more favorable risk/benefit profile. 1 This is particularly relevant for vaginal erosion treatment as these women can safely use oestrogen without endometrial protection. 1

For Women With Intact Uterus

While low-dose vaginal oestrogen typically has minimal systemic absorption, women using higher doses should be monitored, though routine progestogen is generally not required with low-dose vaginal preparations. 1

Formulation Selection

• Vaginal tablets are associated with higher patient satisfaction (69% "extremely satisfied") compared to creams (14% "extremely satisfied") 8
• Vaginal rings offer the simplest regimen with 3-month duration and superior acceptability compared to creams 1, 5
• Creams allow dose flexibility but require more application time (average 5 minutes vs 2.5 minutes for tablets) and are associated with messiness concerns 8

Evidence Quality and Nuances

The 2020 American Journal of Obstetrics and Gynecology guidelines note that preoperative vaginal oestrogen increases vaginal epithelial thickness and maturation index, though evidence for improved surgical outcomes specifically for mesh erosion prevention was not demonstrated in one RCT. 6 However, this does not diminish the established efficacy of vaginal oestrogen for treating existing vaginal erosion and atrophy. 9, 4

A 2016 Cochrane review found no significant difference in efficacy between various intravaginal oestrogenic preparations (rings, tablets, creams), though oestrogen cream showed evidence of increased endometrial thickness compared to oestrogen ring, likely due to higher doses used. 9 This supports using the lowest effective dose and considering non-cream formulations when possible. 1

Common Pitfalls to Avoid

• Do not avoid topical oestrogen due to unfounded safety concerns - it has an excellent safety profile with minimal systemic absorption 1
• Do not use systemic oestrogen instead of vaginal oestrogen for localized vaginal symptoms, as systemic therapy has different risks and may not adequately treat vaginal erosion 1
• Do not underdose - many women using creams apply less than prescribed due to messiness concerns, reducing efficacy 8
• Do not overlook patient preference - satisfaction with the delivery method improves adherence and treatment success 8, 5

Monitoring and Follow-Up

Reassess symptoms at 4-6 weeks after initiating treatment, with formal evaluation at 6-12 weeks for symptom improvement. 3 Continue maintenance dosing (twice weekly) as vaginal atrophy symptoms typically worsen over time without treatment, unlike other menopausal symptoms that may resolve spontaneously. 3