How do I write a prescription for estradiol vaginal suppository 10 µg (0.01 mg) with the appropriate dosing schedule and instructions?

How to Write a Prescription for Estradiol Vaginal Suppository 10 mcg

Write the prescription as: Estradiol vaginal tablets 10 mcg (0.01 mg), dispense #18 tablets, insert 1 tablet vaginally once daily for 2 weeks, then twice weekly for maintenance.

Prescription Format

The standard prescription should include 1, 2:

• Drug name: Estradiol vaginal tablets 10 mcg (or 0.01 mg)
• Quantity: Dispense #18 tablets initially (covers 2-week daily phase plus 2 weeks of twice-weekly maintenance)
• Directions: Insert 1 tablet vaginally once daily at bedtime for 14 days, then insert 1 tablet vaginally twice weekly (e.g., Monday and Thursday) for ongoing maintenance
• Refills: Specify refills as appropriate for long-term therapy

Dosing Schedule

The ultra-low-dose 10 mcg estradiol vaginal tablet follows a two-phase regimen 1, 2:

• Initial phase: 1 tablet vaginally daily for 14 days to restore vaginal epithelium
• Maintenance phase: 1 tablet vaginally twice weekly (with 3-4 days between doses) for ongoing symptom control

This dosing provides only 1.14 mg of estradiol annually, making it the lowest approved dose available with minimal systemic absorption 1, 2.

Mandatory Pre-Prescription Screening

Before writing this prescription, you must 3:

• Confirm negative pregnancy status - estradiol is pregnancy category X
• Measure baseline blood pressure - hypertension increases stroke risk
• Screen for absolute contraindications: active or history of thromboembolic disease (DVT, PE, stroke), uncontrolled hypertension, hepatic disease, breast cancer, endometrial cancer, undiagnosed vaginal bleeding, and migraine with focal neurologic symptoms

Critical pitfall: Do not prescribe to women ≥35 years who smoke, as this substantially increases stroke risk 3.

Progestin Considerations

Women with an intact uterus do NOT require concurrent progestin therapy with the 10 mcg vaginal tablet because the ultra-low dose causes minimal systemic absorption and no increased risk of endometrial hyperplasia 1, 2. This distinguishes vaginal estradiol from systemic hormone replacement therapy, where progestin is mandatory for endometrial protection in women with a uterus 3.

Patient Instructions to Include

Provide these specific instructions 1, 2:

• Insert tablet deep into the vagina at bedtime using the provided applicator
• Some women may experience transient "vaginal warmth" during the first few days - this is normal and resolves 4
• Continue twice-weekly maintenance indefinitely for symptom control
• Report any unusual vaginal bleeding, leg pain/swelling, chest pain, or severe headaches immediately

Monitoring Requirements

After initiating therapy 3:

• Measure blood pressure at every visit - hypertension is a common adverse effect
• Assess for cardiovascular or thromboembolic symptoms at follow-up visits
• No routine endometrial monitoring is required with the 10 mcg dose due to minimal systemic absorption 1

Alternative Formulations

If the 10 mcg tablet is unavailable or not tolerated, alternative vaginal estradiol formulations include 5:

• Estradiol vaginal cream 0.003% (15 mcg per 0.5 g application) - applied twice weekly after initial daily phase
• Estradiol softgel vaginal inserts 4 mcg or 10 mcg - similar dosing schedule 6

The tablet formulation offers advantages of precise dosing, minimal messiness, and excellent patient satisfaction compared to creams 1, 2.