From the Guidelines
Premarin (conjugated estrogens) is a highly effective treatment for vulvovaginal atrophy, and its use is supported by the most recent guidelines, including the NCCN guidelines (1). The typical regimen involves Premarin vaginal cream 0.5-2 g applied intravaginally daily for 1-3 weeks, then reduced to 1-3 times weekly for maintenance therapy. Most patients start with 0.5-1 g containing 0.3-0.625 mg conjugated estrogens per application. The cream should be applied at bedtime for optimal absorption and using the provided applicator for accurate dosing. Improvement in symptoms like vaginal dryness, irritation, and painful intercourse typically begins within 1-2 weeks, with maximum benefit after 4-6 weeks of treatment. Premarin works by delivering estrogen directly to vaginal tissues, restoring thickness, elasticity, and lubrication while minimizing systemic absorption compared to oral estrogen. Patients should be aware that vaginal bleeding, breast tenderness, or headaches may occur as side effects. Regular follow-up with a healthcare provider is important to assess response and adjust dosing as needed. For women with intact uteri using higher doses or longer durations, progesterone therapy may be recommended to prevent endometrial hyperplasia. It's also important to note that the safety of vaginal hormones has not been firmly established in survivors of estrogen-dependent cancers, and therefore, alternative treatments like ospemifene (1) or vaginal androgens (1) may be considered in these cases. However, according to the most recent guidelines (1), 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. Additionally, a large cohort study (1) 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. Therefore, Premarin remains a viable treatment option for vulvovaginal atrophy, especially when used under the guidance of a healthcare provider and with careful consideration of the patient's individual risk factors and medical history (1). Some key points to consider when prescribing Premarin include:
- Starting with a low dose and gradually increasing as needed
- Monitoring for side effects and adjusting the dose or treatment plan accordingly
- Considering alternative treatments for patients with a history of estrogen-dependent cancers
- Providing regular follow-up and education to patients on the proper use and potential risks of Premarin. It's worth noting that other studies (1) have also shown that vaginal estrogens are effective in relieving symptomatic atrophic vaginitis, and that they may be superior to systemic treatment for vaginal dryness. However, the most recent guidelines (1) should be prioritized when making treatment decisions.
From the FDA Drug Label
Treatment of moderate to severe symptoms of vulvar and vaginal atrophy due to menopause. When prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy, topical vaginal products should be considered
Premarin is indicated for the treatment of moderate to severe symptoms of vulvar and vaginal atrophy due to menopause. However, when prescribing solely for this indication, topical vaginal products should be considered as an alternative. 2
From the Research
Treatment Options for Vulvovaginal Atrophy
- Vulvovaginal atrophy (VVA) is a chronic condition caused by estrogen deficiency, affecting around 50% of postmenopausal women 3.
- Topical low-dose estrogens, such as estriol, are effective in treating VVA and alleviating urinary incontinence and preventing recurrent urinary tract infections 3, 4.
- Non-hormonal preparations, such as lubricants and moisturizers, can be used as a first-line treatment for VVA in women taking adjuvant endocrine therapies for cancers considered to be hormone-dependent 3, 5.
Efficacy and Safety of Estriol
- Estriol has been shown to be effective in treating VVA with few adverse effects reported 4, 6.
- Long-term treatment with ultra-low-dose estriol vaginal gel is safe and effective in improving VVA symptoms and signs 4.
- Estriol preparations appear to be safe for women who have risk factors related to systemic estrogen therapy 6.
Comparison of Treatment Options
- A study comparing the therapeutic effectiveness of vaginal estradiol, promestriene, and sodium hyaluronate found that all three treatments were effective in treating VVA 7.
- Promestriene and sodium hyaluronate may be as effective and well-tolerated as vaginal estradiol in the symptomatic treatment of vaginal atrophy 7.