FORT LAUDERDALE, FLA. — Topical estrogen is important to the success of treatment for urogenital atrophy and also has therapeutic value for the management of urinary urgency, frequency, and, most importantly, nocturia, Dr. G. Willy Davila said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.
However, overcoming the fears of patients and oncologists about the safety of localized estrogen remains an uphill battle, said Dr. Davila, chairman of the department of gynecology, urology, and reconstructive pelvic surgery at the Cleveland Clinic Florida, Weston.
“Our task is to allay the fears of patients who come in and have this almost paranoid fear of any estrogen therapy. The main challenge is having the patient be compliant with therapy,” he said.
Patients may be concerned that any form of estrogen might get into the bloodstream. But with vaginal estrogen, the dosage can be tailored so that it is not absorbed systemically, with the result that blood levels of estrogen are negligible, Dr. Davila said.
If vaginal atrophy is not treated, it will progress; advanced urogenital atrophy with increasing degrees of labial fusion is a common occurrence. The traditional treatment has been to lyse the labia, but this will be a stopgap measure only. “The most important issue is not that you lyse the labia, but rather that the patient continue using local estrogen. If the patient does not use local estrogen cream, this fusion will recur fairly promptly,” he said.
Other conditions that respond well to local estrogen therapy include nocturia, dyspareunia, and stress incontinence. For the latter, adding an α-agonist to the estrogen preparation will have a synergistic effect and this can be very useful for stress incontinence in cases of significant atrophy. Local estrogen should also be applied if a woman is using a pessary to prevent erosion and ulceration, Dr. Davila said. Routine measurement of estradiol levels can reassure the patient that she is not absorbing estrogen systemically, he added.
Dr. Vincent Lucente of Temple University School of Medicine, Philadelphia, commented that there are no well-designed clinical trials that look specifically at topical applications of estrogen and urged continued investigation of the subject.