Vaginal Oestrogen

1. Introduction

Vaginal oestrogen is a local hormone replacement therapy (HRT) used to treat symptoms of vaginal atrophy, dryness, and genitourinary syndrome of menopause (GSM). It works by restoring vaginal tissue integrity, increasing lubrication, and reducing symptoms of urinary discomfort without significantly affecting systemic oestrogen levels.

2. Indications

  • Vaginal Atrophy (Postmenopausal Vaginal Dryness, Itching, and Discomfort)
  • Genitourinary Syndrome of Menopause (GSM)
  • Dyspareunia (Pain During Intercourse)
  • Urinary Symptoms (Urgency, Recurrent UTIs, Mild Incontinence)
  • Lichen Sclerosus (Off-Label Use)

3. Dosage

Adults (Postmenopausal Women):

  • Vaginal Tablets (e.g., Vagifem 10 mcg):
    • Loading dose: One tablet daily for 2 weeks, then
    • Maintenance dose: One tablet twice weekly.
  • Vaginal Cream (e.g., Estradiol 0.01% Cream, Premarin Cream):
    • Loading dose: Apply daily for 2 weeks, then
    • Maintenance dose: Apply twice weekly (0.5–1 g per application).
  • Vaginal Ring (e.g., Estring, Femring):
    • Insert one ring every 90 days (releases 7.5 mcg/day of oestrogen).
  • Vaginal Pessary/Gel (e.g., Ovestin 0.5 mg Estriol Pessary):
    • Loading dose: One pessary daily for 2 weeks, then
    • Maintenance dose: One pessary twice weekly.

Elderly:

  • Same dosing as adults but use lowest effective dose to avoid systemic absorption risks.

Renal & Hepatic Impairment:

  • No dose adjustment required, but avoid in severe liver disease due to potential systemic accumulation.

4. Administration

  • Vaginal Tablet: Insert deep into the vagina using the applicator.
  • Vaginal Cream: Apply inside the vagina using the applicator.
  • Vaginal Ring: Insert and leave in place for 90 days.
  • Vaginal Pessary: Insert before bedtime to reduce leakage.

5. Forms Available

  • Vaginal Tablets: 10 mcg estradiol (e.g., Vagifem)
  • Vaginal Cream: 0.01% estradiol or conjugated oestrogens (e.g., Ovestin, Premarin Cream)
  • Vaginal Ring: Estradiol-releasing ring (e.g., Estring, Femring)
  • Vaginal Pessary/Gel: Estriol pessary (e.g., Ovestin 0.5 mg)

6. Side Effects

6.1 Common Side Effects:

  • Vaginal irritation
  • Discharge
  • Breast tenderness

6.2 Less Common Side Effects:

  • Mild spotting
  • Headache
  • Nausea

6.3 Rare but Serious Side Effects:

  • Endometrial Hyperplasia (if used long-term without progesterone)
  • Venous Thromboembolism (VTE) (Minimal risk with vaginal use)
  • Breast Cancer Risk (Minimal with local therapy but long-term effects unclear)

7. Warnings

  • Minimal Systemic Absorption: Unlike oral HRT, vaginal oestrogen does not significantly increase blood oestrogen levels.
  • Endometrial Hyperplasia Risk: Long-term use without progesterone may increase the risk of endometrial hyperplasia or cancer.
  • Avoid in Active Breast Cancer: Contraindicated in women with current or past oestrogen-sensitive cancers.
  • Thromboembolism Risk: Although minimal, use with caution in women with a history of DVT or stroke.

8. Precautions

  • Use the lowest effective dose for symptom control.
  • Women with an intact uterus using high doses long-term may need progesterone protection.
  • Not a contraceptive—use additional birth control if required.

9. Interactions

  • Aromatase Inhibitors (e.g., letrozole, anastrozole): Vaginal oestrogen may reduce effectiveness in breast cancer patients.
  • Systemic Oestrogens (e.g., oral HRT): Avoid combination unless advised by a specialist.
  • Rifampin, Carbamazepine (CYP3A4 Inducers): May slightly reduce vaginal oestrogen effectiveness.

10. Monitoring Parameters

  • Symptom relief (vaginal dryness, pain, urinary discomfort).
  • Spotting or abnormal bleeding (report immediately).
  • Breast changes (self-examination and routine mammograms recommended).

11. Use in Children

  • Not recommended in children or premenopausal women.

12. Use in Pregnancy

  • Contraindicated—not for use during pregnancy.

13. Use in Elderly

  • Safe for postmenopausal women, but monitor for endometrial effects if using long-term.

14. Use in Kidney Disease

  • No specific dose adjustment required.

15. Use in Liver Disease

  • Avoid in severe hepatic impairment due to potential accumulation.

16. Patient Counselling Points

  • Use exactly as prescribed, do not exceed the recommended dose.
  • Apply at night to reduce leakage.
  • Report any unusual bleeding or discharge to your doctor.
  • Not a contraceptive—use additional birth control if required.
  • For vaginal rings, remove after 90 days and replace with a new one.

17. Table of Brand Names, Manufacturer, and Prices in USD

Brand NameManufacturerStrength/Dosage FormPrice (USD)
VagifemNovo Nordisk10 mcg Tablet$100 (24 tablets)
OvestinOrganon0.5 mg Pessary$80 (15 pessaries)
Premarin CreamPfizer0.625 mg/g Cream$120 (30g)
EstringPfizer7.5 mcg/day Vaginal Ring$150 (90 days)
FemringVarious50 mcg/day Vaginal Ring$180 (90 days)

18. 15 FAQs (Frequently Asked Questions)

1. What is vaginal oestrogen used for?
It is used for vaginal atrophy, dryness, and urinary symptoms in postmenopausal women.

2. Does vaginal oestrogen affect libido?
It may improve sexual function by reducing vaginal dryness and discomfort.

3. How long does it take for vaginal oestrogen to work?
Improvement occurs within 2–4 weeks, with full effects in 3 months.

4. Can vaginal oestrogen cause weight gain?
No, weight gain is not a common side effect.

5. Can I use vaginal oestrogen long-term?
Yes, but monitor for endometrial changes if using high doses long-term.

6. Does vaginal oestrogen increase breast cancer risk?
No significant increase in risk with local therapy.

7. Can vaginal oestrogen cause blood clots?
Minimal risk compared to systemic HRT.

8. Can I have sex while using vaginal oestrogen?
Yes, but wait a few hours after application.

9. Can vaginal oestrogen be stopped suddenly?
Yes, but symptoms may return.

10. Can I use vaginal oestrogen with an IUD?
Yes, it does not interfere with intrauterine devices.

11. Is vaginal oestrogen the same as oral HRT?
No, it is local and has minimal systemic absorption.

12. Can I take vaginal oestrogen with progesterone?
Only necessary if using high doses long-term.

13. How is the vaginal ring removed?
Simply pull out gently, dispose of it, and insert a new one.

14. Does vaginal oestrogen help UTIs?
Yes, it can reduce recurrent UTIs by improving vaginal flora.

15. How should vaginal oestrogen be stored?
Store at room temperature, away from heat.