Vaginal Estrogen – Less May Be More

If there’s one thing I’ve learned over the years when it comes to medications, it’s this – more is not necessarily better. You can have too much of a good thing, and less can sometimes be more.

Certainly that’s been the mantra when it comes to hormone replacement in menopause. Since the WHI findings were released in 2002, we’ve all been going lower and lower with estrogen dosing, and finding that, for many women, it’s more than enough to treat the symptoms.

Now, a new low dose formulation of vaginal estrogen, Vagifem 10 ug, approved in Dec 2009, has hit the market. I have to say that I am thrilled to have this option for my patients.(I know, some of you are in shock that I would actually be talking favorably about a new drug, but hey, when they get it right, they get it right.)

Research has shown that vaginal 10 ug estradiol tablets are effective in treating symptoms of postmenopausal vaginal atrophy and dryness. While the previously marketed 25 ug vaginal estradiol preparation was superior in some measures when the two were compared, the lower dose may be all that some women need.

Why go lower dose? After all, the 25 ug vaginal estradiol dose is pretty darned low, and does not typically lead to elevation of estrogen levels above the normal postmenopausal background after the first two weeks of use. But I have had occasional patients complain of breast tenderness in those first two weeks of more intense Vagifem use (you use it once a night in the beginning, then twice a week after that) and even one or two for whom the use of vaginal estrogen triggered a headache. I’ve been anxiously waiting for the lower vaginal dosing ever since the research was published on its relative efficacy. Glad to see it’s finally here.

Medicare recently moved this Vagifem off its preferred formulary, which has been a real problem for a lot of my older patients who no longer can afford it, even though they prefer it over the vaginal creams. As do I, since absorption is probably lower with the vaginal tablets than the creams. (The vaginal ring had the lowest systemic absorption until now, but unfortunately it is too large for some women to use.)  Fortunately, we can customize the cream to a lower dose by just using less of it.

Of course, some women, particularly those at increased risk for breast cancer, are uncomfortable with estrogen in any form. For these women, there are over the counter vaginal moisturizers. And a good  lubricant is helpful for sexual activity, even for some women using vaginal estrogen.

The big question is, will this new low dose vaginal estrogen be low enough for women using aromatase inhibitors? These women suffer terribly from vaginal dryness, but even vaginal estrogen may be too much for them, since we aim for serum estrogen levels of zero in this group. It’s an important question that will need to be studied before any of us are comfortable using even this lower dose preparation in this important subgroup of postmenopausal women.

6 Responses to Vaginal Estrogen – Less May Be More

  1. I agree with the information regarding the prescribed level of the estrogen found in the female body which is responsible for the genitals and behaviour characters.I like the point of the replacement of the bonds link in the favour that it may be the reason of tablets taken for manupose.I know that the good lubricant is helpful for sexual activity, even for some women using vaginal estrogen.

  2. This is good news–where are my drug reps when I need information like this? A lot of my patients get breast tenderness from Vagifem which makes them…and me…nervous. Even the oncologists like the Estring, but dang, it's SO pricey. Actually, the cream is rather pricey, and gooey!, too.

    I've found Premarin cream works very well for menopausal women with rectal complaints–dryness, itching, hemorrhoids that won't calm down. I think the rectal mucosa and anal skin must also suffer from lack of estrogen.

  3. I agree with the information regarding the prescribed level of the estrogen found in the female body which is responsible for the genitals and behaviour characters.I like the point of the replacement of the bonds link in the favour that it may be the reason of tablets taken for manupose.I know that the good lubricant is helpful for sexual activity, even for some women using vaginal estrogen.

  4. Does the low dosage of vaginal estrogen stop or reverse the shrinking and narrowing of the vagina and does it prevent labia,clitoral atrophy?

    • Vaginal estrogen in general will prevent vaginal atrophy and loss of vaginal capacity as one goes through the years past menopause. Add in regular sexual activity for the best results at maintaining vaginal comfort. I have found that some women who are regularly sexually active throughout menopause have not needed estrogen. And some who have started using estrogen after long periods of sexual inactivity who need vaginal dilators in addition to estrogen to restore capacity. Masturbation and judicious vibrator/dilator use are ways to maintain capacity in between relationships. (I advise my patients not to use a vibrator or dilator if they are not using vaginal estrogen – it risks tearing the tissues).

      Replens and other vaginal moisturizers are alternatives to estrogen for maintaining the vaginal tissues in menopause, and I advise women who want to avoid estrogen in any form to try this first.

      I don’t know of good data re impact of estrogen on labial and clitoral changes with age – most of the studies on vag estrogen assess its impact on vaginal epithelial cells and subjective complaints of dryness and dyspareunia. Labial and clitoral changes would require much longer studies – none are longer than 6 months to my knowledge. So many other factors impact the labia and clitoris – weight change, testosterone levels, sexual activity, and just general changes in skin with aging that are independent of menopause. But in general, I would say that yes, estrogen would be expected to help in this regard.

      Thanks for reading.

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