From the Guidelines
Estrogen cream is a highly effective treatment for menopausal symptoms, particularly vaginal dryness, pain during intercourse, and urinary symptoms, and should be considered as a first-line treatment option. According to the most recent and highest quality study, 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 1. Common prescription options include Estrace (estradiol) cream 0.01%, Premarin (conjugated estrogens) cream 0.625 mg/g, and Estring (estradiol vaginal ring). For vaginal symptoms, a typical regimen involves applying a pea-sized amount of cream into the vagina using an applicator, usually once daily for 1-2 weeks, then decreasing to 2-3 times weekly for maintenance.
Some key points to consider when prescribing estrogen cream include:
- The treatment can continue as long as symptoms persist, often for years
- These topical estrogens work by restoring vaginal tissue thickness, increasing blood flow, and improving lubrication
- Unlike oral estrogens, vaginal creams have minimal systemic absorption, resulting in fewer side effects and no significant increased risk of blood clots, stroke, or breast cancer
- Some women may experience mild irritation or discharge initially
- Women with a history of breast cancer, blood clots, or certain liver conditions should discuss risks with their healthcare provider before using estrogen cream
- Regular follow-up appointments are important to monitor effectiveness and adjust dosing as needed
It's also important to note that a large cohort study 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 1. However, the safety of vaginal hormones has not been firmly established in survivors of estrogen-dependent cancers, and therefore should be used with caution in these patients.
From the FDA Drug Label
Estradiol valerate injection, USP is indicated in the: Treatment of moderate to severe vasomotor symptoms associated with the menopause. Treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with the menopause. When prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy, topical vaginal products should be considered.
The answer to the question about estrogen cream topical for menopause is that the drug label does not specifically mention estrogen cream, but it does mention topical vaginal products for the treatment of symptoms of vulvar and vaginal atrophy associated with menopause.
- The label indicates that estradiol valerate injection is used for the treatment of moderate to severe vasomotor symptoms and symptoms of vulvar and vaginal atrophy associated with menopause 2.
- However, it suggests considering topical vaginal products for vulvar and vaginal atrophy, implying that topical products may be used for certain menopause symptoms, but it does not explicitly mention estrogen cream.
From the Research
Estrogen Cream Topical for Menopause
- Estrogen cream is a topical treatment option for menopausal women experiencing vaginal atrophy and sexual dysfunction 3.
- Topical vaginal estrogen preparations can reverse atrophic changes and relieve associated symptoms, while avoiding systemic effects 4.
- Local vaginal therapy with estrogen creams, rings, or tablets may be more appropriate for women without other indications for systemic estrogen therapy 3.
- Estrogen therapy is a logical treatment option for menopausal women with sexual dysfunction, as estrogen loss is a significant cause of sexual dysfunction in this population 3.
- Topical estrogen therapy can improve vaginal health and sexual functioning, and may have effects on other dimensions of sexual function 3.
Alternatives to Estrogen Cream
- Nonhormonal medications, such as selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors, can be used to treat vasomotor symptoms, but are not effective for vaginal atrophy 5.
- Hormone-free vaginal moisturizers are noninferior to estrogen-based therapies for treating genitourinary syndrome of menopause 5.
- Other treatment options for vaginal dryness and dyspareunia associated with menopause include ospemifene and intravaginal dehydroepiandrosterone 5.
Importance of Treatment
- Vaginal atrophy and sexual dysfunction can significantly impact a woman's quality of life, and timely diagnosis and treatment can lead to restoration and maintenance of vaginal function and health 6.
- Many women with vaginal atrophy do not receive adequate therapy, often due to lack of education and discussion about the condition 7, 6.
- Healthcare providers should encourage women to seek help for vaginal atrophy and sexual dysfunction, and provide education on available treatment options 7, 6.