Contraindications to Vaginal Estrogen Cream for Vaginal Atrophy
Vaginal estrogen cream is contraindicated in women with current or history of hormone-dependent cancers (breast, endometrial, ovarian), undiagnosed abnormal vaginal bleeding, active or recent pregnancy, active liver disease, and recent thromboembolic events. 1
Absolute Contraindications
The following conditions represent absolute contraindications where vaginal estrogen should not be prescribed:
- History of hormone-dependent cancers including breast cancer, endometrial cancer, or ovarian cancer 1
- Undiagnosed abnormal vaginal bleeding that has not been evaluated and diagnosed 1
- Active or recent pregnancy 1
- Active liver disease 1
- Recent thromboembolic events including deep venous thrombosis or pulmonary embolism 1
Special Considerations for Breast Cancer Survivors
While breast cancer represents a contraindication, the evidence shows nuance in this population:
- Non-hormonal options must be tried first for at least 4-6 weeks, including vaginal moisturizers 3-5 times weekly and water-based lubricants during sexual activity 1
- If non-hormonal measures fail, low-dose vaginal estrogen can be considered only after thorough discussion of risks and benefits with both the patient and her oncologist 1
- A large cohort study of nearly 50,000 breast cancer patients followed for up to 20 years showed no increased risk of breast cancer-specific mortality with vaginal estrogen use, providing reassurance when the decision is made to proceed 1
- For women on aromatase inhibitors, estriol-containing preparations may be preferable as estriol is a weaker estrogen that cannot be converted to estradiol 1
- Vaginal DHEA (prasterone) is specifically recommended for aromatase inhibitor users who haven't responded to non-hormonal treatments 1
Important Clarifications
What is NOT a Contraindication
- Bladder cancer is not a hormone-dependent malignancy and does not represent a contraindication to vaginal estrogen therapy 2
- History of hysterectomy is not a contraindication; in fact, estrogen-only therapy is specifically recommended for women who have had a hysterectomy due to its more favorable risk/benefit profile 3
- History of endometriosis treated with hysterectomy is not an absolute contraindication to low-dose vaginal estrogen 1
Systemic Estrogen Risks Do Not Apply
The Women's Health Initiative risks for cardiovascular events, stroke, and breast cancer were observed with oral conjugated equine estrogen, but these systemic risks do not apply to low-dose vaginal estrogen formulations. 3 Large prospective cohort studies of over 45,000 women show no concerning safety signals for stroke, venous thromboembolism, invasive breast cancer, colorectal cancer, or endometrial cancer with low-dose vaginal estrogen formulations. 2
Common Pitfall to Avoid
Do not confuse systemic hormone therapy contraindications with vaginal estrogen contraindications. The USPSTF recommendation against systemic hormone therapy for chronic disease prevention does not apply to vaginal estrogen for treatment of symptomatic vaginal atrophy. 1 Low-dose vaginal estrogen has minimal systemic absorption and a fundamentally different safety profile than oral or transdermal systemic hormone therapy. 3, 4