The fear of vaginal estrogen

After practicing medicine for almost 25 years, certain patterns become very clear. We try to create processes in the office to help prevent common bottlenecks that affect access to care for our patients. The one pattern that I can’t seem to mitigate is the fear of vaginal estrogen.Genitourinary syndrome of menopause (GSM) is the updated terminology for genital, sexual and urinary symptoms caused by thinning of the muscles and lining of the bladder and vagina. After menopause, 60% of women notice vaginal dryness and pain with intercourse. The symptom that people don’t always link to menopause is bladder irritability and urge incontinence. Most attribute this to childbirth or aging, and don’t realize that this is directly related to low estrogen. Approximately 30% of post-menopausal women have symptoms of OAB. The yearly incidence of bladder infections is 30% in women 85+, and the risk of sepsis increases drastically as we age.People are often referred to urologists when these symptoms become debilitating and are prescribed anticholinergic medications like Ditropan or Myrbetiq. But these medications come with side effects that seriously decrease quality of life including dizziness, constipation, and dry mouth. Those little old ladies crinkling their candy wrappers at the theatre are likely taking Ditropan. However anticholinergics don’t address the root cause of most post-menopausal bladder irritability, which is often low estrogen. A comparison of the estradiol ring to oral oxybutynin showed similar efficacy for treatment of overactive bladder but with different adverse effects; oxybutynin resulted in more dry mouth, constipation and blurry vision, whereas the estradiol ring resulted in more vaginal discharge. I know which side-effect profile I’d prefer! The efficacy of vaginal estradiol was confirmed in a Cochrane review.When my patients think about taking hormone therapy in menopause they imagine swallowing a pill that increases estrogen levels in the blood. They’ve heard that menopausal hormone therapy (MHT, previously called HRT) increases the risk of cancer and stroke and they think that their little bladder problem isn’t worth having a stroke for! To make matters worse, all estrogen products sold in Canada have big warning stickers that say “The Women’s Health Initiative (WHI) trial examined the health benefits and risks of oral combined estrogen plus progestin therapy (n=16,608) and oral estrogen-alone therapy (n=10,739) in postmenopausal women aged 50 to 79 years. The estrogen-alone arm of the WHI trial (mean age 63.6 years) indicated an increased risk of stroke and deep vein thrombosis in hysterectomized women treated with CEE-alone (0.625 mg/day) for 6.8 years compared to those receiving placebo. ” When we prescribe estrogen to treat GSM, the amount of estrogen used is a much lower dose than in the WHI study. Comparing low-dose vaginal estrogen to full-dose MHT is like comparing a OTC hydrocortisone to pulse prednisone. They are not the same thing. The North American Menopause Society has been campaigning to have these black box warnings removed because they are just not appropriate to display on vaginal estrogen products. Low-dose vaginal estrogen is such a tiny dose that it’s undetectable in blood tests. It doesn’t cause blood clots or strokes or cancer. It just helps the bladder and vagina work better. It’s such a minimal amount of hormone that it does not affect endometrial tissue. Multiple studies also show no change in recurrence or survival rates for patients who have breast cancer. The U.K. is way ahead of us in North America; you can buy vaginal estrogen over the counter there—because it is safer than Tylenol. The American Urological Association calculated the overall cost savings for vaginal estrogen treatment for women with recurrent bladder infections to be $1226 to $4888 annually per patient. How much are your patients spending on incontinence pads and pelvic physiotherapy? Do they have increasing restrictions on their activity to ensure they’re always near a bathroom?Agony is optional and vaginal estrogen is safe. The only warning I routinely give is to call the office if they have vaginal bleeding, which is an instruction we should relay to all post-menopausal women. The incidence of post-menopausal bleeding is about 5%, and most is caused by atrophy. Vaginal estrogen dosed correctly will not cause vaginal bleeding, but it may unmask an existing polyp, hyperplasia or cancer. Note that if you’re prescribing MHT/HRT (oral estrogen or patch) you may also need to prescribe vaginal estrogen. Oral MHT often doesn’t improve genitourinary symptoms.Some urologists think that every post-menopausal woman should be using vaginal estrogen. I wouldn't go that far, but I do prescribe it for patients who are distressed by pain, irritation and urinary symptoms. I give them all a heads-up about the warning label and the fact that it is incorrectly applied to this product. Still, 80% of my patients fill the prescription and never take it. If you’ve got great strategies for compliance, please share them in the comments.

The fear of vaginal estrogen

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Kim Alexander

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