From the Guidelines
Topical estrogen therapy is the most effective treatment for vaginal dryness leading to sexual dysfunction in postmenopausal women, and it has been shown to be safe and effective in treating itching, discomfort, and painful intercourse. According to the NCCN guidelines 1, vaginal estrogen is a recommended treatment option for survivors with sexual dysfunction. The guidelines suggest that vaginal estrogen can be used to treat vaginal dryness, itching, discomfort, and painful intercourse in postmenopausal individuals.
Some of the prescription options for topical estrogen therapy include:
- Estradiol vaginal cream (Estrace, 0.01%, typically 2-4g applied vaginally 1-2 times weekly)
- Estradiol vaginal tablets (Vagifem, 10mcg inserted vaginally twice weekly)
- An estradiol vaginal ring (Estring, replaced every 90 days) These preparations work by directly delivering estrogen to vaginal tissues, restoring thickness, elasticity, and lubrication while minimizing systemic absorption 1.
It's worth noting that the safety of vaginal hormones has not been firmly established in survivors of estrogen-dependent cancers 1. However, 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.
Treatment usually begins with daily application for 1-2 weeks, then decreases to a maintenance schedule of 1-3 times weekly. Most women experience significant symptom improvement within 2-4 weeks of starting treatment, though therapy typically continues long-term as symptoms often return when treatment stops 1. Side effects are uncommon but may include local irritation or mild vaginal discharge.
In addition to topical estrogen therapy, other treatment options such as pelvic physical therapy, vaginal dilators, and other medications like ospemifene and flibanserin may also be considered for survivors with sexual dysfunction 1. However, topical estrogen therapy remains the most effective treatment for vaginal dryness leading to sexual dysfunction in postmenopausal women.
From the Research
Topical Estrogen Therapy for Postmenopausal Women
- Topical estrogen therapy is effective in managing postmenopausal vaginal atrophy, a condition that affects up to 60% of women, with significant impact on their quality of life 2.
- Symptoms of vaginal atrophy are more common and severe in breast cancer survivors, and topical estrogen preparations can reverse atrophic changes and relieve associated symptoms without systemic effects 2.
- Low-dose estradiol vaginal cream (0.003%) applied twice per week is an effective and well-tolerated treatment for vulvovaginal atrophy (VVA) symptoms and dryness associated with menopause 3.
Safety and Efficacy of Topical Estrogen Therapy
- Topical low-dose estrogens are effective and also alleviate urinary incontinence and prevent recurrent urinary tract infections, with reassuring safety data for long-term use 4.
- Non-hormonal preparations (lubricants and moisturizers) should be the first-line treatment for VVA in women taking adjuvant endocrine therapies for cancers considered to be hormone-dependent 4.
- Low-dose estrogen therapy has been shown to decrease hot flashes, preserve bone density, and have a better vaginal bleeding profile compared to traditional doses, but may not completely avert breast tenderness and skeletal effects 5.
Considerations for Menopausal Hormone Therapy
- Menopausal women with an intact uterus choosing estrogens for menopausal symptom relief require a progestogen for endometrial protection, with various progestogens available for combined menopausal hormone therapy (MHT) 6.
- The choice of progestogen and regimen should be individualized, taking into account the risks of endometrial hyperplasia and malignancy, as well as the availability of different progestogen formulations 6.