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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
- See Also
- Menopause
- Estrogen Replacement
- Continuous Estrogen Replacement
- Sequential Estrogen Replacement
- Transdermal Estrogen
- Indications
- Atrophic Vaginitis in Menopause
- Postmenopausal Dyspareunia
- Precautions
- Higher dose Topical Estrogens require concurrent Progesterone if Uterus intact (risk of Endometrial Hyperplasia)
- Lower dose Topical Estrogens do not require systemic Progesterone (in intact Uterus) if used <1 year
- Obtain Transvaginal Ultrasound (endometrial stripe) and Endometrial Biopsy if vaginal spotting or bleeding
- Some guidelines allow use of low dose Topical Estrogens indefinately
- No consistent guidelines as whether low dose agents require Progesterone with prolonged use >1 year
- Krause (2009) J Pelvic Med Surg 15(3): 105–14 [PubMed]
- Preparations: High Dose Topical Estrogens
- Indicated for vasomotor symptoms AND Genitourinary Syndrome of Menopause (Vaginal Atrophy)
- Requires concurrent progesteron use
- Estradiol acetate vaginal ring (FemRing)
- Placed in vagina and replaced every 90 days
- Available as 0.05 and 0.1 mg/day rings
- Requires opposing Progesterone if Uterus intact (risk of Endometrial Hyperplasia)
- Preparations: Low Dose Topical Estrogens
- Indicated for Genitourinary Syndrome of Menopause
- Estradiol Vaginal Ring (Estring)
- Placed in vagina and replaced every 90 days
- Available as 2 mg rings (releases 7.5 mcg estradiol per day)
- Estradiol Vaginal Tablet (Vagifem, Yuvafem)
- Initial: One tablet intravaginally daily for 2 weeks
- Later: One tablet intravaginally twice weekly
- Available in 10 mcg and 25 mcg applicators
- May be safe at low dose, low frequency use despite history of Breast Cancer
- Low systemic absorption at low dose
- Requires Informed Consent regarding potential risks and lack of safety studies following Breast Cancer
- Pruthi (2012) Mayo POIM Conference, Rochester
- Estradiol vaginal soft gel (Imvexxy)
- Released in 2018 at $180/month or twice the cost of generic vaginal creams
- Gel is applied manually (without applicator) twice weekly
- (2018) Presc Lett 25(9): 53
- Estrogen Cream (Premarin or Estrace Creams)
- Premarin (Conjugated Estrogen 0.625 mg per 1 g cream)
- Apply 0.5 g (up to 2 g) daily for 21 of every 28 days OR
- Apply 0.5 g applied intravaginally twice weekly
- Estrace (Estradiol)
- Apply 2-4 g daily for 2 weeks, then reduce to 0.5 g twice weekly
- Prasterone or DHEA (Intrarosa)
- Although marketed as non-Estrogen, it is DHEA which converts to Estrogens and androgens in vaginal tissue
- Released in U.S. in 2017
- (2017) Presc Lett 24(9): 53
- References
- Hill (2016) Am Fam Physician 94(11): 884-9 [PubMed]
- Ringel (2020) Am Fam Physician 102(9):550-7 [PubMed]