Vaginal Estrogen for Postmenopausal Women

A session at the recent Nurse Practitioners in Women’s Health annual conference focused on vulvovaginal changes that occur during menopause, the effects of atrophic vaginitis on postmenopausal women, and the use of vaginal estrogen treatment.

In this exclusive MedPage Today video, Kendra Roloff, DNP, of Pelican Health in Bismarck, North Dakota, discusses the main points from her presentation.

Following is a transcript of her remarks:

Hello, my name is Kendra Roloff, and I’m a women’s health nurse practitioner specializing in pelvic health incontinence. Today I will be discussing a topic that affects nearly 50% of postmenopausal women. It feels like a taboo subject for most. Today’s discussion will be on vaginal estrogen for postmenopausal women.

As women age and enter into the menopausal years, the level of estrogen diminishes, which can severely affect a woman’s vaginal health. In the absence of estrogen, the vaginal epithelium thins, the vaginal rugae diminish, and the tissues become avascular and dry. These changes contribute to a wide variety of lower urinary tract symptoms, including painful intercourse, burning with urination, vulva itching and irritation, and urinary urgency and frequency. Genital urinary syndrome of menopause (GSM) is the term used to describe the large spectrum of symptoms women experience mainly due to the lack of estrogen.

Now it’s important to note that GSM is chronic and progressive. Unlike basal motor symptoms, such as hot flashes experienced by menopausal women. Hot flashes tend to dissipate the further a woman progresses into menopause. Whereas GSM tends to progress.

The use of local vaginal estrogen can provide many benefits for postmenopausal women, including restoration of vaginal pH, maturation of vaginal epithelial cells, improved blood flow, improved elasticity and improved lubrication. Long-term use of vaginal estrogen is recommended for postmenopausal women as they are not receiving estrogen from any other source.

Various formulations exist for vaginal estrogen and while one formulation is not superior to another, some forms of vaginal estrogen are better for some women than others. The various forms include vaginal estrogen cream, a vaginal estrogen ring, vaginal estrogen tablets, and the vaginal estrogen suppository.

Despite the benefits of vaginal estrogen, barriers for its use do exist. Based on studies, women are most concerned with safety related issues, such as side effects, the increased risk for breast cancer, and systemic absorption. Now in regard to safety concerns, systemic absorption is minimal and serum estradiol levels do remain within the postmenopausal reference range while utilizing vaginal estrogen. In addition, studies support that vaginal estrogen can safely be used for women with a history of gynecologic cancer and heart disease, and even most women with a history of breast cancer.

Much of the lack of understanding surrounding vaginal estrogen dates back to the women’s health initiative study, which was published in 2002. Unfortunately the study grouped both oral and vaginal estrogen together, so there was quite a bit of unnecessary concern surrounding the use of vaginal estrogen. As we know, vaginal estrogen is not systemically absorbed as oral estrogen is, and therefore does not carry the same risk. However, black box warnings do not reflect that. Therefore, we continue to struggle with fear and negativity surrounding the use of vaginal estrogen. This emphasizes just how important it is to educate women on the difference between oral and vaginal estrogen, and that vaginal estrogen is indeed safe to utilize.