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Estrogen Cream Makes Me Wet Again

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  • PMC3252029

J Pelvic Med Surg. Author manuscript; bachelor in PMC 2012 Jan 5.

Published in last edited form every bit:

PMCID: PMC3252029

NIHMSID: NIHMS343702

Local Furnishings of Vaginally Administered Estrogen Therapy: A Review

Megan Krause

oneUniversity of Kansas Medical Eye, Kansas City, KS Department of Obstetrics and Gynecology

Thomas L. Wheeler, Ii

2University of South Carolina Greenville Campus, Greenville, SC Section of Obstetrics and Gynecology

Thomas East. Snyder

1University of Kansas Medical Middle, Kansas City, KS Department of Obstetrics and Gynecology

Holly E. Richter

3Academy of Alabama at Birmingham, Birmingham, AL Department of Obstetrics and Gynecology

Abstract

The results of the Women'southward Health Initiative (WHI) led to a distinct decline in the routine employ of estrogen as preventive therapy for vasomotor symptoms, osteoporosis, and cardiovascular disease in postmenopausal women. Without estrogen replacement, one third of women experience symptoms of atrophic vaginitis including dryness, irritation, itching and or dyspareunia. Local application of estrogen has been shown to relieve these symptoms and meliorate quality of life for these women. In add-on, local estrogen therapy may take a favorable consequence on sexuality, urinary tract infections, vaginal surgery, and incontinence. This review examines the effects of vaginally applied estrogen on the vaginal epithelium, urethra and endometrium. An accompanying review examines the systemic furnishings of vaginally practical estrogen.

Keywords: vaginal estrogen, vaginal cloudburst, menopause, quality of life

Introduction

Following publication of the results of the Women'south Health Initiative (WHI) trial, about women are no longer routinely placed on estrogen replacement as a preventive therapy. Without estrogen replacement, the vaginal epithelium and underlying connective tissue can thin, and for a 3rd of women, this results in dryness, discomfort, itching, and/or painful intercourse, often referred to as atrophic vaginitis. Transvaginal estrogen is generally used to help postmenopausal women specifically with vaginal and lower urinary tract symptoms such as dryness and dyspareunia, urgency and frequency, as well equally urinary tract infections.1,2 Furthermore, gynecologic surgeons often pre-treat vaginal atrophy prior to performing surgery for pelvic flooring disorders such every bit incontinence and prolapse. The purpose of this report is to review the affect of various forms of transvaginal estrogen on the urogenital tract (vagina, endometrium and bladder). Systemic effects are detailed in the companion review to this commodity.three

The Vagina as Drug Delivery System

In 1918 Macht demonstrated that the vagina was able to absorb drugs including morphine and atropine. While drugs administered vaginally are often used to treat local conditions, these drugs may also act systemically.four Some oral agents are ordinarily used vaginally for non-FDA indications such as misoprostol for labor induction. Oxybutynin was initially marketed as an oral formulation and now is available in a vaginal band for treatment of overactive bladder. The apply of the vagina every bit a drug commitment system will most likely go on to increment considering of the many qualities that make information technology suitable for absorption of drugs. Oral administration of drugs may exist complicated by vomiting, variations in GI assimilation, and drug interactions. Similarly, transdermal application is susceptible to variable outcomes based on levels of adiposity. I of the major advantages of vaginally administered drugs is avoidance of "hepatic first pass effect", which affects the absorption, distribution and excretion of orally administered drugs. This results in utilise of lower doses to reach equivalent therapeutic effect.4 Likewise, patients may benefit from less frequent dosing which decreases fluctuations in drug levels and tin can outcome in fewer side effects.four

Ane business organization many patients have nigh vaginally applied medications is that it will "fall out."4 However, the proximal vagina is relatively horizontal in the upright female and the vaginal rugae provide adequate surface area for drug absorption. In addition, innervation of the vagina is mainly concentrated in the distal portion, while the horizontally positioned proximal portion is more often than not devoid of sensory endings, making drug application more comfortable. Finally, the vagina is a highly vascular organ, resulting in a gear up epithelial/vascular interface for absorption. One interesting upshot of the large claret supply surrounding the vagina is the "showtime uterine pass effect" which results in higher uterine levels of a vaginally applied drug compared to systemic administration.4,5 Some other reward is the discreet nature of vaginal administration. I of the few disadvantages of vaginally administered medications is overcoming patients' initial reluctance to utilize this method of administration due to misinformation.four

Based on the patient's preference, at that place are multiple options for vaginal hormone commitment. Two vaginal creams are available: one with estradiol (Estrace®, 0.1 mg estradiol/gm cream) and one with conjugated equine estrogens (Premarin®, 0.625 mg CEE/gm foam). There is also a vaginal tablet with (Vagifem®), 25.8μg of estradiolhemihydrate equivalent to 25 μg of estradiol. In addition there are vaginal rings: Femring® with available doses of either 50 μg/day or 100 μg/twenty-four hours, Estring® with 7.5 μg/day, and a combined estradiol/progesterone band, which is non currently available commercially in the US.

Local Vaginal Effects

Notelovitz et al.6 examined the local vaginal effects of vaginal tablets at two dissimilar doses: x and 25 μg. Participants were treated for a total of 12 weeks. The results of the treatment on vaginal maturation was measured past the vaginal maturation alphabetize (VMI), a surrogate mensurate of vaginal cloudburst which measures estrogenic effect by examining the percentage of superficial cells which are mature epithelial cells with small nuclei due to an estrogenic effect. The report showed significant improvement afterward 12 weeks of treatment, where lx% of subjects in each treatment group had increased maturation values. A relationship betwixt increased maturation values and serum Eii levels, however could not be demonstrated.6

The effects of vaginal rings containing estradiol on the vaginal epithelium have likewise been studied. In a study of Femring®, the number of superficial cells increased by sixteen% and eighteen% with 50 μg and 100 μg, respectively, of estradiol, in comparison to 1.eleven% increment with placebo. Vaginal pH decreased with use of Femring® by 0.73 and 0.6 pH units for 50 μg and 100 μg respectively, with placebo use resulting in a 0.25 pH unit of measurement subtract.7

Femring® was studied in postmenopausal women by Speroff for the U.s. Vaginal Ring (VR) Investigational Group (2003).viii With both doses studied, the mean change in the maturation index of vaginal cells from baseline to final evaluation was significantly greater for both doses than placebo. Subsequently completion of the study, no women on the fifty μg/day dose and only 1 woman on 100 μg/twenty-four hours (5%) had vaginal cloudburst while 6 women (15%) on placebo continued to exhibit vaginal cloudburst.8

Estring® is a vaginal ring containing ii mg of estradiol released at a rate of 7.v μg/twenty-four hour period for xc days. The utilize of the Estring® was compared to conjugated estrogen vaginal cream and no departure was noted in efficacy or comeback of vaginal dryness and atrophy both from a physicians' and patients' assessment. In i study, Estring® showed an 83% improvement compared to 82% for the vaginal cream, while another study showed Estring® improved symptoms in 79% versus 75% for the foam.9

Estring® had like efficacy to conjugated estrogen vaginal cream in its ability to decrease pH as well as promote vaginal cell maturity.9 Furthermore, the employ of the Estring® resulted in no cases of endometrial hyperstimulation as compared to conjugated estrogen foam where 11% of participants had resulting endometrial overstimulation.9 Estring® also exceeded vaginal cream in comfort as judged by patients with Estring® being rated equally fantabulous or very expert comfort for 95% compared to 65% for the cream. Ease of use for Estring® was judged first-class or very good in 95% compared to 88% for the vaginal foam.9

Vaginal Estrogen: Urinary Tract Infections and Lower Urinary Tract Symptoms

Urinary Tract Infections

In a study by Eriksen,x postmenopausal women who experienced greater than iii urinary tract infections in the prior year were treated with Estring® to exam prevention of recurrence compared to placebo. Estring® was shown to result in a significantly college cumulative proportion of participants without recurrent urinary tract infections compared to placebo. After 30-six weeks, 45% of participants on Estring® did not have a recurrence compared to twenty% of those on placebo (P=0.008) (Fig 1). In addition, Estring® resulted in a meaning decrease in vaginal pH past 12 weeks of therapy. Vaginal and urethral epithelium were more mature based on cytologic findings every bit determined by examination of the number of parabasal cells, intermediate cells and superficial cells in vaginal and urethral smears.x

An external file that holds a picture, illustration, etc.  Object name is nihms-343702-f0001.jpg

Time to first recurrence curves for control and Estring-treated subjects by intent-to-treat (ITT) and per-protocol (PP) groupings. Kaplan-Meier analysis shows that cumulative proportion of subjects remaining gratuitous of urinary tract infection was significantly college in vaginal ring group than in control group (P = .008 by log-rank test).

Reference: Erikson B. A randomized, open, parallel-group report on the preventive effect of an estradiol-releasing vaginal ring (Estring) on recurrent urinary tract infections in postmenopausat women. Am J obstet Gynecol 1999; 180: 1072-1079.

Erikson. Kaplan-Meier curve showing pct costless from urinary tract infections with Estring every bit compared to placebo.

Float Storage Symptoms and Urinary Incontinence

The subtract in ovarian estrogen production at the fourth dimension of menopause causes atrophic changes in the vulvar, vaginal, urethral and bladder tissue. While vasomotor symptoms may resolve in a few months or years, vaginal and other urogenital symptoms may actually increase as the patient ages. 11 The effects of estrogen are manifest by the presence of Estrogen Receptors (ERs). Estrogen receptors have been shown in biopsy specimens from the bladder trigone, proximal urethra, distal urethra, vagina and vesico-vaginal connective tissue contiguous with the bladder neck.12, 13,14 While ERs were present in urethral squamous epithelium, they were not present in urothelial tissue of the lower urinary tract. Progesterone receptors are more variable and found mostly in subepithelial tissues.

Decreased estrogen levels after menopause causes atrophic urogenital symptoms with several recent studies confirming resultant dysuria and other lower urinary tract symptoms such as urgency and frequency. Iosif studied a cohort of Swedish women and plant a 50% incidence of urogenital symptoms including dryness, itching, burning, urgency and frequency.15 Barlow reported that 23-40% of menopausal women report at least ane urogenital symptom.sixteen In a 1954 paper, Youngblood 17 reported that symptoms of urgency and irritation were due to "atrophic urethritis" which is divers at symptoms of UTI without a positive civilisation.

Another written report examined the effects of vaginal hormonal therapy on the urinary tract of postmenopausal women mail hysterectomy by evaluating the blood menstruation at the urethral neck after either 0.625 mg oral or vaginal conjugated estrogen cream.18 The urethral vascular network contributes significantly to urethral epithelial coaptation pressure which may influence some types of urinary incontinence. One measurement of blood catamenia is the pulsatility index; the greater the blood menstruum, the lower the pulsatility index. Handling with both oral and vaginal estrogen resulted in significantly lower pulsatility index compared to baseline.18 Additionally, in that location was a significant increase in the number of periurethral vessels with both treatment options. Symptoms of urinary frequency and nocturia showed a significant decrease for both oral and topical treatment subsequently three months. While in that location was no significant modify in the prevalence of stress and urge incontinence every bit measured by urodynamic studies, subjective symptom improvement of stress incontinence was reported in 72.7% of participants using oral replacement compared to threescore% in the topical estrogen group.18 A sub-study of the WHI showed an increase in stress urinary incontinence in postmenopausal women after oral estrogen/progestin therapy, merely in women under the age of 60 at that place was no meaning increase.19 In contrast, the Hormone and Urogenital Therapy Committee reviewed 35 manufactures on stress incontinence which showed a subjective improvement in stress incontinence ranging from 64-75% with intravaginal and/or oral estrogen therapy.20 Currently, the role of intravaginal estrogen in the handling of stress incontinence is not clear.

Local estrogen therapy has been shown to increase urethral closing pressure with improvement of urge incontinence symptoms.21 The women who experienced relief were found to have concurrent squamous metaplasia of the lower urethral transitional epithelium. In add-on, uninhibited bladder contractions were noted to decrease in those using vaginal estrogen.21 The apparent paradox of comeback in stress and urgency symptoms with local estrogen in some studies, and lack of improvement in stress incontinence symptoms every bit noted in the HERS study 22 may be partially explained if one assumes that the major outcome of local estrogen is to improve urethral epithelium and coaptation without affecting the anatomic urethral supporting mechanisms. Farther show for a direct effect of local estrogen on the urethral epithelium was provided by Bhatia who showed that menopausal women utilizing intravaginal estrogen demonstrated more mature/superficial epithelial components in urethral swabs compared to untreated women.21 These women were also noted to have fewer symptoms of atrophic urethritis than controls.

It is difficult to perform studies of relief of vaginal and urinary symptoms since both have been reported to improve without agile intervention and with awarding of non medicated lubricants and placebo creams.23,20 Herbal therapy had not been shown to improve symptoms24 and vaginal lubricants are less effective than estrogens.25

The issue of nocturia has been addressed in a recent Cochrane review which examined a variety of estrogen therapies and plant no deviation in frequency, nocturia or urgency.26 In improver, Lose27 studied 251 women treated with either an oestradiol releasing ring or oestradiol pessaries for 24 weeks. Subjective scores for urgency, frequency, nocturia, dysuria, stress incontinence, and urge incontinence were examined. Fifty one percent of the patients treated with the ring had improvement in nocturia versus 54% with the pessary. Sixty percent of patients rated the ring as first-class versus 14% for the pessaries. There was no placebo group in this trial. Finally, Simunic et al studied the effects of intravaginal estrogen in patients with urogenital symptoms using 25 μg of 17ß estradiol or placebo for 12 months. After 12 months of therapy, urinary atrophy symptoms defined as complaints of dysuria, frequency, or urinary incontinence or greater than two UTIs in the by year were nowadays in 35.9% of patients treated with placebo versus merely 15.5% of patients treated with estradiol.28 Nocturia and frequency was reduced from 32.8% in patients treated with placebo to nine.4% in the estradiol group. In this study, information technology appears that intravaginal estrogen has a favorable effect on both vaginal irritative symptoms as well equally urinary incontinence.

Estring® has besides shown improvement in symptoms of dysuria and urinary urgency. In a US study conducted by the manufacturer, symptoms of dysuria and urinary urgency improved in 74% and 65% of patients receiving Estring® as assessed by the patients only. In a companion Australian study, symptoms of dysuria and urinary urgency improved in 90% and 71% respectively, of patients receiving Estring®, once again assessed by the patients in the study population.

Vaginal Estrogen and Sexual Part

It is well established that estrogen deficiency occurring at and beyond menopause may disrupt many of the physiological responses which narrate sexual arousal, including shine musculus relaxation, vasocongestion and vaginal lubrication.29 The decreased lubrication and tissue elasticity in addition to shortening of the vaginal vault tin crusade dyspareunia.29 In addition, decreased sensory response and patient reaction to her social situation, loss of a long-term partner, changes in body image, and medication may cause undesired alterations in sexual habits. Other factors which may contribute to decreased sexual function include length of relationships, aging, physical and mental health problems, loss of partner'due south health, medication use, and other financial and social stressors.30 The intent of this department is to address only those changes that may exist affected by utilize of various forms of vaginal estrogen administration.

There is a strong correlation between serum levels of estradiol, vaginal atrophy and subsequent dyspareunia. Although both estradiol and estrone product decreases following menopause, estrone becomes the predominant estrogen in the postmenopausal menstruation. While there is little change in testosterone levels associated with menopause, testosterone levels decrease with age because of decreased adrenal androgen synthesis.31, 32 Ovarian stromal cells continue to produce pre-androgen and testosterone.33 Therefore, in the postmenopausal woman, estrogen is produced extragonadally from ovarian and adrenal androgens.30 Women whose estradiol levels are > 50 pg/ml have been shown to take less vaginal dryness and dyspareunia during sex activity. In add-on, decreased coital activity is associated with estradiol levels < 35 pg/ml.29,34 As previously noted in this review and elsewhere, topical estrogen can improve vaginal lubrication and reduce dryness and dysparunia.34,35,36 In add-on, information technology has been shown that relief of these symptoms may increased quality of life, arousal and orgasmic role.37,38

Bachmann, and others 38,39 noted that restoring vaginal epithelial health with estrogen results in increased vaginal compliance,39decreased vaginal pH, increased vaginal blood menstruation and lubrication.34 Changes in vaginal fluids and electrolytes have been noted with i month of therapy40 and in pH, blood flow and vaginal electropotential in 18-24 months.40 Women later report decreased vaginal irritation, pain, dryness42 and burning during intercourse,42,41 which may pb to increased sexual desire,34 arousal 40,43 and improved quality of life.42

Multiple studies have examined the effects of oral and transdermal estrogen on sexual office. Nevertheless, few studies have evaluated the effects of vaginal estrogen lonely for improvement in sexual role. Gast, et al enrolled 285 good for you sexually agile post menopausal women anile 45-65 years in a study of oral depression dose conjugated estrogen (CEE) 0.45 mg/medroxyprogesterone 1.5mg for six, 28 24-hour interval cycles forth with 1 gm CEE (0.625mg) vaginal cream for the first six weeks of the trial versus a placebo cream and tablet.44 The efficacy of the regimens was assessed by the McCoy Female Sexuality Questionnaire, self reported daily diary cards, the Brief Index of Sexual Functioning -Women (BISF-Westward) and the Women's Wellness Questionnaire. The author found that the estrogen therapy (ET) group had a significant decrease in frequency of dyspareunia compared to placebo and baseline by the McCoy Female person Sexuality Questionnaire. ET was likewise associated with improvement in the level of sexual interest, frequency of orgasm, and pleasure of orgasm. However, there was no effect on coital frequency in this report. In another written report, Cayan reviewed 169 women who received either oral 17β East2 (Hormone Therapy, HT), 17βE2 plus drosperinone, oral tibilone or vaginal 17β estradiol alone. 45 Sexual function was evaluated with a xix-item questionnaire, the Sexual Function Index, including evaluation of sexual desire, arousal, lubrication, orgasm, satisfaction and pain. In the women studied, the sexual function score increased in the hormone therapy (HT) grouping and decreased in the control group. The all-time comeback in total score and arousal was in the hormone therapy group while the highest improvement in lubrication was in the oral and vaginal 17ß estradiol group. As well, the best comeback in hurting was in the oral and vaginal 17β estradiol groups. Yet, the vaginal therapy only group did not accept a favorable response in desire, arousal, orgasm or satisfaction compared to the oral 17β Due eastii grouping.45

Vaginal Estrogen and Surgery

It is normally believed and anecdotal experience would predict that a well-estrogenized vagina heals better and is more resistant to complications such as infections and mesh erosions than more poorly estrogenized tissue. Many expert gynecologic surgeons recommend both pre- and postoperative vaginal estrogen for postmenopausal patients. Notwithstanding, at that place are few studies bachelor which straight address the issue of vaginal estrogen on perioperative outcome.

Information technology is known that topical estrogen can treat age-related peel changes such as wrinkles and sparse peel.46 Estrogen also increases the rate of cutaneous wound healing in older women and men. Estrogens act on the cutaneous wound healing response past modulating the inflammatory response, cytokine expression and matrix degradation. They besides accelerate re-epithelialization, stimulating angiogenesis and wound contraction, and regulate proteolysis.46 While estrogens' impact wound on healing of nonkeratinized vaginal epithelium remains to be described, its potential positive bear upon, currently adds to the rationale for perioperative use in vaginal surgery. There are no studies that direct compare the ease of the surgical procedure or its outcomes in women pretreated with intravaginal estrogen compared to those without treatment with intravaginal estrogen.

Vaginal Estrogen and the Endometrium

Intravaginal application of estrogen plays a unique role in hormone replacement therapy because of evidence that there is preferential delivery of hormones supplied in the vagina to the endometrium. This has been termed the "kickoff uterine laissez passer consequence." This phenomenon is theorized to exist the result of countercurrent exchanges with vein to avenue improvidence. While this phenomenon is known to occur in the upper third of the vagina; it was unclear if this occurs throughout the vagina. A recent study examined this phenomenon. Vagifem® was applied in postmenopausal women either in the lower or upper third of the vagina. Estradiol levels forth with Doppler velocity measurements were made both at baseline and after 2 hours. Awarding to the upper third of the vagina resulted in statistically significant higher serum estradiol levels simply simply a small absolute difference compared to the lower 3rd of the vagina. Also, with application of Vagifem® to the upper third of the vagina, there was a decrease in pulsatility alphabetize and resistance index which was not seen with lower third application. Thus, the start pass uterine result appears to exist exclusive to the upper third of the vagina. With awarding to the lower third of the vagina there was preferential delivery to the periurethral surface area.47

One major business concern of unopposed long-term intravaginal estrogen therapy is the effect on the endometrium. One component of the Postmenopausal Estrogen/Progestin Interventions Trial examined the furnishings of oral estrogen alone compared to oral estrogen plus progesterone and placebo. Oral conjugated estrogens administered without concomitant progestin increased diverse forms of hyperplasia, 27% of cases resulting in simple hyperplasia compared to 8% with placebo. Hyperplasia rates in patients who received progesterone were similar to placebo. The subsequent addition of progestin after unopposed estrogen treatment resulted in hyperplasia reverting to normal in 94% of cases.48

In a report of 159 patients, Vagifem® tablets given daily for 2 weeks, then twice weekly, were compared to CEE vaginal cream 1.25 mg for 3-week cycles over half dozen months. There was similar improvement in symptoms of vaginal dryness, soreness, and irritation in both the Vagifem® and comparator group. No statistical differences were found on endometrial biopsies that were performed to appraise the presence of endometrial hyperplasia or malignancy with Vagifem apply. Like rates of endometrial cloudburst were noted in the Vagifem® and placebo group (84%and 86% respectively). In that location was one patient whose biopsy showed simple hyperplasia in the Vagifem® group (iii%) vs none in the placebo group. No patients in either group showed complex hyperplasia or malignancy.49 Another arm of the study compared endometrial biopsy data of patients treated with Vagifem® to CEE over 24 weeks. Xxx-4 (68%) of the Vagifem® group vs xv (30%) of the CEE grouping showed atrophy, 2% vs 14% weakly proliferative endometrium, 0% vs 2% simple hyperplasia, and 0% vs ii% circuitous hyperplasia. Insufficient tissue was noted in 28% vs 42% of Vagifem®- and CEE- treated patients, respectively.

Weisberg et al examined the results of 48 weeks of utilise of Estring® and Vagifem® on vaginal symptoms including vaginal dryness, puritis, dyspareunia, and endometrial changes associated with menopause. In that location was no change in endometrial thickness over the first 12 weeks of observation for either group. Haemorrhage occurred in iv patients using Vagifem® while no patients had haemorrhage with Estring®.50 Some other cess of endometrial response was performed past Naessen and Rodriguez-Macias.51 They compared 12 months of Estring® use to placebo. Endometrial thickness did not increment with prolonged use of Estring®. Baseline endometrial diameter was 2.8 mm and at the conclusion of the study 12 months later was 2.6 mm. Endometrial thickness was noted to exist associated with waist circumference, body mass index (BMI), and estradiol levels.51

A study by Maruo et al.52 posed the question: does the addition of progesterone to estradiol in vaginal rings forestall endometrial proliferation in postmenopausal women? Ii doses of progesterone were tested: approximately v mg/twenty-four hours and 9 mg/twenty-four hour period, combined with estradiol released at approximately 150 μg/24-hour interval. Serum estradiol levels reached a peak level of 69 pg/ml at 2 weeks and decreased to 36 pg/ml at 6 months. Estrone levels remained stable at a mean level of 94 pg/ml. The high dose progesterone studied reached a peak serum level of 4.viii ng/ml at ii weeks and then decreased to 2.6 ng/ml at vi months. Similarly, the depression dose progesterone reached a maximum serum concentration of 2.8 ng/ml and decreased to 1.4 ng/ml. (Fig ane) Biopsies were obtained at 4 months, but simply 5 of 17 women who had biopsies performed had sufficient tissue for analysis. Of those with sufficient tissue, glands and stroma were thin. The authors concluded that both doses of progesterone contained within the band were sufficient to foreclose endometrial proliferation. Participants also had fewer days of haemorrhage compared to their pretreatment status. For months ii-iv, 51% of participants experienced no bleeding. In addition, vasomotor symptoms, vaginal conditions including dryness, dyspareunia, discharge, and mood were improved relative to pretreatment.52

No consensus has been reached regarding the need for monitoring for changes in the endometrium when unopposed depression-dose intravaginal estrogen is used. MacLennnan and Sturdee argued that monitoring is not required.53 There are two elements to their argument. The start is that endometrial screening is costly and has low specificity; the 2d is that the run a risk of endometrial cancer after vaginal estrogen use is undefined. Besides, estrogen-induced endometrial cancers exercise not appear to exist associated with increased mortality thus limiting the benefits of expensive screening. In that location is no current consistent opinion or objective data that demonstrates the requirement for the use of progesterone in women given vaginal estrogen of any blazon. Endometrial proliferation requires estradiol levels higher than normal postmenopausal levels which do not consistently occur with intravaginal estrogen application. In improver, endometrial cancers often present with vaginal bleeding which makes detection easier.53 The Cochrane Database does non show evidence of endometrial proliferation or cancers with unopposed depression dose vaginal estrogen but at that place have been no long term studies. It does suggest that progesterone should exist added if there is systemic absorption as suggested by administration of greater than 0.5 mg/twenty-four hour period.54

Conclusion

For postal service-menopausal women who feel vaginal and lower urinary tract symptoms and do not wish to take oral estrogen, the use of intravaginal estrogen can offer meaning benefit with low risk. Depending on the patient's specific needs, individualization of various handling types and amounts is possible. It is of import to counsel our post-menopausal patients about the benefits and risks of this treatment option, especially as more women are proactively seeking care that improves vaginal health and subsequent quality of life. Decisions regarding the form of intravaginal estrogen, as well as the need for intermittent progestin treatment should exist individualized.

An external file that holds a picture, illustration, etc.  Object name is nihms-343702-f0002.jpg

Hateful Serum Levels of Estradiol, Estrone and Progesterone before and during band employ. The number of subjects contributing samples is indicated for each time point. Values from users of the 2 ring types are combined for estradiol and estrone.

Reference: Maruo T, Mishell DR, Ben-Chetrit A, et al. Vaginal rings delivering progesterone and estradiol may be a new method of hormone replacement therapy. Fertil Steril 2002; 78: 1010-1016.

Acknowledgement

Partially supported by the National Institute of Diabetes and Digestive and Kidney Diseases DK068289 to HER.

Partially supported past a Dennis W. Jahnigen Career Evolution Award to TLW

Footnotes

This paper is based on an oral presentation by Dr. Snyder on May 6, 2008 at the 2008 American Higher of Obstetricians and Gynecologists Annual Clinical Meeting, New Orleans, Louisiana.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3252029/