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Vaginal estrogen safe for post-menopausal women

March 12, 2019 | UCI Health
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Although estrogen replacement had been linked to an increased risk of cardiovascular disease and cancers, a landmark new study demonstrates no rise in risk for women using topical estrogen for relief of genitourinary syndrome.

“It’s really important to differentiate between systemic estrogen replacement and topical estrogens,” says UCI Health urogynecologist Dr. Felicia Lane. “This new study shows that topical applications — unlike systemic estrogen replacement — do not increase the risk of blood clots, cardiovascular disease, osteoporosis or breast and endometrial cancers.”

The nearly 20-year follow-up study of 53,000 nurses, which was published in December, 2018, found that despite its “black box” warning, low-dose vaginal estrogen does not increase risk.

“This has always been our bias,” says Lane, who leads UCI Health Urogynecology Services. “Now we have some great evidence.”

What happens in menopause?

Menopause, which is defined as an absence of menstrual periods for 12 months, results in the reduction of circulating estrogen. Doctors sometimes treat menopausal symptoms such as hot flashes, night sweats and mood changes, with systemic hormone replacement therapy in the form of pills or patches.

These therapies, which were not included in the recent study, have previously been linked to cardiovascular and cancer risk. Lane still advises women to talk with their doctors about the benefits and risks of these systemic therapies.

Other vexing problems associated with menopause occur when decreased circulating estradiol, a form of estrogen, and lower blood flow to the genitals and urinary tract causes the vulva, vagina and urethra to get thinner and drier. The condition, known today as genitourinary syndrome (GSM), continues to progress as women grower older, especially after age 65.

These symptoms can be treated successfully with topical estrogen, says Lane, who is also a professor in the UCI School of Medicine’s Department of Obstetrics & Gynecology and chief of its Division of Urogynecology.

What are the symptoms of GSM?

About 40 percent of women will develop GSM after menopause. There are two categories of symptoms.

Genital:

  • Dryness
  • Burning
  • Irritation

Urinary tract:

  • Urgency
  • Dysuria
  • Recurrent urinary tract infections

“If you’re having symptoms of GSM, we recommend topical therapy,” Lane says. “It replaces estrogen just in that area where you’re having problems, thickening the skin within a few days so that the estrogen applied does not circulate in the bloodstream.”

What topical estrogen treatments are available?

Topical vaginal estrogen treatment can produce great improvement in just eight to 12 weeks. It can be applied in different ways:

  • Suppositories inserted in the vagina with an applicator two to three times a week at bedtime
  • Creams applied vaginally twice a week at bedtime
  • A ring, inserted in the vagina every three months by a provider or patient, that releases low doses of estrogen daily

Who shouldn’t use these topical treatments?

Women who are not candidates for vaginal estrogens — those who’ve had breast cancer or a recent stroke — may consider non-estrogen lubricants such as Vitamin E suppositories or prasterone cream. “These women need to have a conversation with their doctors about the right therapy,” Lane says.

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