Important Disclaimer: I am NOT a physician. I am a physiotherapist. Any decision to use or take a medication must be discussed with your physician.
In my practice, I have seen local vaginal estrogen prescribed for women by their physicians yielding beneficial results. Local vaginal estrogen is estrogen that is applied specifically inside and/or around the entrance of the vagina and vulvar vestibule. There are reasons for (indications) and reasons against (contra-indications) the prescription and use of local estrogen. Your complete medical history and presentation of symptoms needs to be taken into consideration when you and your doctor discuss the risks vs. benefits of using local estrogen for your specific case.
So why is estrogen important? And why, specifically, at the vulva and vagina?
First, a little background. The vagina, lower urinary tract, and pelvic floor all come from the same embryologic origin (1,6) and therefore all contain estrogen receptors. These tissues can undergo atrophy in estrogen deficient states such as menopause (whether from natural occurrence or medically induced; 1,6) and in the postpartum period (2). The postpartum woman experiences a decline in estrogen levels with the loss of placental estrogen and the antagonistic action of prolactin on estrogen production during lactation (2,5).
The Journal of Obstetrics and Gynaecology Canada (JOGC) article Urogenital Health (1) describes changes that occur with declining estrogen on the vulva and vagina. These include:
- The vulva losing collagen (a structural protein that provides a scaffold for strength and structure of a tissue) and adipose tissue (fatty tissue that provides cushioning)
- The vulva becoming flattened and thin
- Glandular secretions diminish
- Atrophy of the prepuce (fold of skin that surrounds the clitoris) of the clitoris which increases the potential for irritation from clothing and sexual contact
- The vagina becoming thinner, less elastic and more friable
- Delaying of the production of fluid during sexual stimulation
- Altering of urethral and vaginal flora (remember the discussion on normal bacteria in the vagina in my biology of a healthy vagina blog – link to this coming soon!) resulting in a less acidic (more basic) pH predisposing both the vagina and lower urinary tract to infection.
Ahinoam, L.’s study on Postpartum Dyspareunia (painful intercourse) Resulting from Vaginal Atrophy (2) adds to the effects of declining estrogen:
- Vaginal mucosa becomes thin and pale or hyperemic and looses flexibility
- Blood flow decreases
- Maturation of epithelial cells do not take place in the absence of estrogen
Symptoms of vaginal and vulvar atrophy can include:
- Vaginal and/or vulvar dryness, pruritis (itchiness), or burning
- Vulvar and/or vaginal pain with or without contact (sexual, medical or clothing)
- Dysuria (pain with voiding) when a urinary tract infection has been ruled out
There is a spectrum to which each women experiences symptoms of hypoestrogenization (lower than normal levels of estrogen). A consultation with a physician is recommended if a woman is experiencing any of the above symptoms.
How common is vaginal and vulval atrophy in menopause?
Dennerstein et. al (3) reported vaginal dryness in 21% of women within one year of menopause and 47% by 3 years after the menopausal transition. Many women are reluctant to seek medical help. Proposed reasons include embarrassment and complacency. Nappi and Kokot-Kierepa (4) conducted a survey that found 45% of the participants reported troublesome vaginal symptoms but only 4% attributed their symptoms to vaginal atrophy. It was also reported that of the 500 Canadians in the survey, 52% were unaware of the effects of local (vaginal) estrogen therapy, and 59% claimed their health care provider never raised the subject of vaginal health.
What about the postpartum period?
It has been reported that 50-60% of women have dyspareunia (painful intercourse) 6 to 7 weeks following delivery, and 33% and 17% will still report pain during intercourse three and six months after delivery, respectively (2). It is has been proposed that the vaginal atrophy due to the lack of estrogen could be a cause of the high rate of postpartum dyspareunia. These authors compared findings of postpartum dyspareunia in both vaginal delivery and cesarean section delivery and found no difference in prevalence between the groups, therefore ruling out mechanical trauma (for example perineal tearing/laceration, stretching and swelling) to the vagina and pelvic floor as the main cause for development of postpartum dyspareunia (2).
It has been suggested by Ahinoam and colleagues (2) that although most gynecologists recognize atrophy in menopausal women, vaginal atrophy is not correctly recognized in most postpartum women and therefore does not receive attention and proper treatment.
How do these changes affect the woman?
The changes that occur at the vulva and vagina due to declining levels of estrogen can a striking effect on a woman’s quality of life. Understandably, there might be a loss of arousal and interest in sex when there is pain at the vagina. Pre-existing vestibulodynia can be flared. Secondary vestibulodynia may begin as a result of persistence in painful penetration setting up the pain sensitization condition. It has been suggested that the lower levels of estrogen in the lower urinary tract and pelvic floor might contribute to the initiation of and/or compound existing issues such as stress urinary incontinence, bladder urgency and urgency related urinary incontinence, and pelvic organ prolapse (5). As mentioned above, the increase in pH predisposes the vagina and lower urinary tract to infection.
What can be done?
As it turns out, a lot! Multiple studies report a reversal of the symptoms and clinical presentation of vaginal atrophy with estrogen therapy. Estrogen can be prescribed systemically (has effect throughout the entire body) as well as locally (applied to a specific area – in this case the vulva and/or the vagina). Your doctor can walk you through the different options of estrogen therapy and review the pros and cons of each. Systemic estrogen (taken orally, with a transdermal patch or a cream or gel applied to areas such as the inner thighs, abdomen, inner arm, wrists) can also provide relief from other signs and symptoms of estrogen decline such as hot flashes, bone loss, and mood swings. However, the American Family Physician article Atrophic Vaginitis (5) states that standard dosages of systemic estrogen, may not eliminate the symptoms of atrophic vaginitis in 10 to 25 percent of patients. The authors suggest that in these cases either the systemic administration should be prescribed in higher doses, or co-administration of a vaginal estrogen product that is applied locally to the vagina and vulvar vestibule. The authors also clarify that up to 24 months of therapy may be necessary to totally eradicate dryness, although unfortunately some patients might not fully respond to this regimen.
And not to be forgotten is education! Become informed about your vagina and about the changes that can occur with declining estrogen. Seek help if you are experiencing bothersome symptoms. Talk to your doctor. Talk to other women, your sisters, mothers, aunts, and your daughters. Knowledge is power.
Are there any risks to estrogen therapy?
Throughout my practice I have been in contact with many physicians and gynaecologists. I have asked every one about the risks of local estrogen application and all have reported that there are very little to no risks. I have been told by a few gynaecologists that the risks of local estrogen are benign.
This is an article that I like to share with women who are concerned about the risks of low-dose local estrogen to explain how boxed warning on the labels and package inserts for these products overstate potential risks: Why the Product Labeling for Low-Dose Vaginal Estrogen Should Be Changed.
Here is a study looking at the effectiveness and safety of local estrogen therapy for women who have survived breast cancer: (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3862044/#__ffn_sectitle).
All concerns about the risks of estrogen therapy should be discussed with your physician.
What type of estrogen, how much, how frequent, and how long should estrogen therapy be used?
Over the years of my practice I have seen many different practice patterns of physicians regarding their prescription of local estrogen therapy.
I have been told that originally, local estrogen therapy was administered via an estrogen cream (in a larger amount/volume that is prescribed in present day) that was drawn up via a syringe and then injected into the vagina. This larger amount of cream was nice and messy, and spilled out to coat and treat the vulvar vestibule (the area within labia minora) as well as taking effect within the vagina.
Then Vagifem came along, a vaginal suppository tablet that was tidy and clean and did not spill out of the vagina to create the messy effect the cream did. That also meant that the effect of the estrogen therapy was not having an effect at the vulvar vestibule – where symptoms of atrophy can also occur. Unfortunately, a physician may recognize the signs and symptoms of hypoestrogenization and resultant vulvar and/or vaginal atrophy, and prescribe the tablet form of local vaginal estrogen. This method will only have effect intravaginally, so when the woman reports no relief of her symptoms of the vulva it is erroneously determined that she failed estrogen therapy - but the real problem is that the estrogen therapy did not get to the right spot. Often local vaginal estrogen therapy by form of cream applied to the vulvar vestibule is all that is needed to relieve symptoms if the woman is only experiencing atrophic symptoms at the vestibule (which is the most common presentation).
In my practice in British Columbia, I have seen a variety of forms and types of local (vaginal) estrogen prescribed to women. I have encountered:
- vaginal suppository tablets (Vagifem)
- intravaginal rings that release estrogen (Estring)
- a variety of creams including Premarin, Estragyn, as well as compounded versions of Estradiol or Estriol (two different types of estrogen) mixed in a hypoallergenic galaxal base
- prescriptions of Estradiol at 0.5 mg/g of galaxal base
- prescriptions of Estriol at 0.3 mg/g of galaxal base
- Moegele et. al (6) suggests an ultra low dosed formulation of Estriol at 0.03 mg/g of galaxal base for women who have survived breast cancer
- Some physicians have prescribed a compound of an estrogen blended with 2-5% lidocaine (a numbing agent) in a galaxal base.
For the cream application it is usually a pea-sized or a rice-sized amount applied at the vulvar vestibule, and then another small amount to be injected in the vagina (if your physician has deemed that intravaginal application will also be beneficial for you) or intravaginal application via tablet or ring. It will be up to you and your physician to decide which type of local estrogen and how much will be best for you.
I have seen a range of dosing in terms of frequency and duration.
- On the lowest end, I have seen application or use of the local estrogen at 2x/week
- Most often I see a loading dose of a daily application for 1-2 weeks followed by 2x/week thereafter (I have seen this prescribed in the postpartum period and in the menopausal period)
- Moegele et. al suggests a once daily application for the first 3–4 treatment weeks followed by a maintenance therapy of 2–3 applications per week (of the 0.03 mg Estriol/g galaxal base; 6) for a population of women who have survived breast cancer
- On the highest end, I have seen a twice daily application x6 weeks, followed by a daily application x6 more weeks followed by a re-assessment by the physician (I have seen this prescribed in the menopausal period)
How long you are prescribed to use the estrogen will likely depend on if you are in the postpartum period (estrogen will at some point return to typical levels) or if you are menopausal (estrogen will not be returning to typical levels). Ask your physician how long to stay on the medication. I have heard physicians suggest to stay on local estrogen in the postpartum period until the woman has had three regular periods back. It would make theoretical sense to continue the local estrogen cream in the menopausal period indefinitely, but this needs to be clarified with your physician for your individual case.
Conditions such as vestibulodynia, stress urinary incontinence, bladder urgency and urgency related urinary incontinence, and pelvic organ prolapse are amendable to physiotherapy intervention. They can also be affected by declining levels of estrogen especially during the postpartum period and in menopause. Consultation with a physician to discuss potential use of estrogen therapy in conjunction with physiotherapy may improve prognosis and resolution of these specific conditions.
1. JOGC September 2014. Chapter 5 - Managing Menopause. Urogenital Health. S35-41. http://dx.doi.org/10.1016/S1701-2163(15)30461-8 (accessed April 24, 2017)
2. Ahinoam L. Postpartum Dyspareunia Resulting From Vaginal Atrophy. ClinicalTrials.gov Identifier: NCT01319968. Last updated April 7, 2015. https://clinicaltrials.gov/ct2/show/NCT01319968 (accessed April 24, 2017)
3. Dennerstein L, Dudley EC, Hopper JL, Guthrie JR, Burger HG. A prospective population-based study of menopausal symptoms. Obstet Gynecol 2000;96:351-8.
4. Nappi RE, Kokot-Kierepa M. Vaginal health: insights, views and attitudes (VIVA) – results from an international survey. Climacteric 2012;15:36-44.
6. Moegele M, Buchholz S, Seitz S, Lattrich C, Ortmann O. Vaginal Estrogen Therapy for Patients with Breast Cancer. Geburtshilfe Frauenheilkd. 2013 Oct; 73(10): 1017–1022. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3862044/#__ffn_sectitle) (accessed April 24, 2017)