Vaginal Estrogen

Aka: Vaginal Estrogen, Topical Estrogen, Estrogen Vaginal Preparation, Estradiol Vaginal Ring, Estrogen Ring, FemRing, Estring, Estradiol Vaginal Tablet, Vagifem, Estrogen Cream, Premarin Cream, Estrace Cream, Prasterone, Intrarosa

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II. Indications

  1. Atrophic Vaginitis in Menopause
  2. Postmenopausal Dyspareunia

III. Precautions

  1. Higher dose Topical Estrogens require concurrent Progesterone if Uterus intact (risk of Endometrial Hyperplasia)
  2. Lower dose Topical Estrogens do not require systemic Progesterone (in intact Uterus) if used <1 year
    1. Obtain Transvaginal Ultrasound (endometrial stripe) and Endometrial Biopsy if vaginal spotting or bleeding
    2. Some guidelines allow use of low dose Topical Estrogens indefinately
    3. No consistent guidelines as whether low dose agents require Progesterone with prolonged use >1 year
    4. Krause (2009) J Pelvic Med Surg 15(3): 105–14 [PubMed]

IV. Preparations: High Dose Topical Estrogens

  1. Indicated for vasomotor symptoms AND Genitourinary Syndrome of Menopause (Vaginal Atrophy)
  2. Requires concurrent progesteron use
  3. Estradiol acetate vaginal ring (FemRing)
    1. Placed in vagina and replaced every 90 days
    2. Available as 0.05 and 0.1 mg/day rings
    3. Requires opposing Progesterone if Uterus intact (risk of Endometrial Hyperplasia)

V. Preparations: Low Dose Topical Estrogens

  1. Indicated for Genitourinary Syndrome of Menopause
  2. Background
    1. Minimal Estrogen absorption and may safely be used at any age (even with Cardiovascular Risks)
    2. Avoid in Breast Cancer Survivors unless allowed by oncology in patients with refractory genitourinary symptoms
  3. Estradiol Vaginal Ring (Estring)
    1. Placed in vagina and replaced every 90 days
    2. Available as 2 mg rings (releases 7.5 mcg Estradiol per day)
  4. Estradiol Vaginal Tablet (Vagifem, Yuvafem)
    1. Initial: One tablet intravaginally daily for 2 weeks
    2. Later: One tablet intravaginally twice weekly
    3. Available in 10 mcg (typical use) and 25 mcg applicators
    4. May be safe at low dose, low frequency use despite history of Breast Cancer
      1. Low systemic absorption at low dose
      2. Requires Informed Consent regarding potential risks and lack of safety studies following Breast Cancer
      3. Pruthi (2012) Mayo POIM Conference, Rochester
  5. Estradiol vaginal soft gel (Imvexxy)
    1. Released in 2018 at $180/month or twice the cost of generic vaginal creams
    2. Available as 4 mcg dose (menopausal Dyspareunia) and a 10 mcg dose
    3. Start with one vaginal insert once daily for 2 weeks
    4. Next insert once twice weekly
    5. (2018) Presc Lett 25(9): 53
  6. Estrogen Cream (Premarin or Estrace Creams)
    1. Premarin (Conjugated Estrogen 0.625 mg per 1 g cream)
      1. Apply 0.5 g (up to 2 g) daily for 21 of every 28 days OR
      2. Apply 0.5 g applied intravaginally twice weekly
    2. Estrace (Estradiol)
      1. Concentration: 0.1 mg Estradiol per 1 g cream
      2. Apply 2 to 4 g intravaginally daily for 2 weeks, then reduce to 0.5 to 1 g twice weekly
  7. Prasterone or DHEA (Intrarosa)
    1. Although marketed as non-Estrogen, it is DHEA which converts to Estrogens and androgens in vaginal tissue
    2. Use one vaginal insert nightly
    3. Released in U.S. in 2017
    4. (2017) Presc Lett 24(9): 53

VI. References

  1. (2022) Presc Lett 29(11): 66
  2. Chang (2023) Am Fam Physician 108(1): 28-39 [PubMed]
  3. Hill (2016) Am Fam Physician 94(11): 884-9 [PubMed]
  4. Ringel (2020) Am Fam Physician 102(9):550-7 [PubMed]

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Related Studies

Cost: Medications

femring (on 1/1/2023 at Medicaid.Gov Survey of pharmacy drug pricing)
FEMRING 0.05 MG/DAY VAG RING $664.72 each
FEMRING 0.10 MG/DAY VAG RING $712.28 each
estring (on 7/12/2023 at Medicaid.Gov Survey of pharmacy drug pricing)
ESTRING 2 MG VAGINAL RING $507.72 each
ESTRING 7.5 MCG/DAY (2 MG) RING $507.72 each
vagifem (on 2/23/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
VAGIFEM 10 MCG VAGINAL TAB Generic $7.56 each
intrarosa (on 1/1/2023 at Medicaid.Gov Survey of pharmacy drug pricing)
INTRAROSA 6.5 MG VAG INSERT $8.74 each
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

Related Topics in Pharmacology

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