The authors report no financial relationships relevant to this article.
The authors would like to acknowledge Lauren Melcher, MD, an ObGyn resident at Washington Hospital Center, who contributed to this article.
CASE: New-onset dyspareunia in a menopausal patient
J. B., 53 years old, has been menopausal for 2 years. Several months after her annual examination, she schedules another appointment to discuss a worsening complaint: dyspareunia. She says she never had the problem until she reached menopause, and reports that it has become so severe that she has started avoiding sexual intercourse altogether. Even when she avoids intercourse, however, she is bothered by vaginal itching and burning.
What can you offer to her?
Various hormonal and nonhormonal products are available to relieve the frequent complaint, in menopausal women, of symptoms of vaginal atrophy: vaginal dryness, itching, burning, and dyspareunia.1-3 The array of products isn’t really surprising: As women advance through menopause, their complaints of vaginal dryness increase fivefold.4
Systemic and local estrogen therapies reverse some atrophic changes and alleviate symptoms.5 After menopause, local vaginal estrogen formulations are recommended as first-line treatment for women who experience moderate or severe symptoms of vaginal atrophy.3 Formulations such as the vaginal ring, vaginal tablet, and transdermal gels and sprays are increasingly popular.
In this article, we describe these and other products, including nonhormonal lubricants and moisturizers, to relieve:
- the range of symptoms of vaginal atrophy in menopausal women
- isolated vaginal dryness in premenopausal women.
When a postmenopausal woman complains of chronic vaginal dryness, and the exam is consistent with vaginal atrophy, the recommended treatment is local vaginal estrogen. If she complains of vaginal dryness during sexual intercourse only, a vaginal lubricant is a suitable option.
When a premenopausal woman complains of vaginal dryness, a vaginal moisturizer is the best long-term treatment option. However, a vaginal lubricant is recommended for intermittent dryness during intercourse or dyspareunia.
Local estrogens avoid many risks of systemic therapy
Topical estrogen preparations are available as vaginal creams, tablets, and rings, and as transdermal lotions, gels, and patches (TABLE 1). Local preparations are preferred to systemic therapy for the treatment of atrophy because they bypass the gastrointestinal tract, undergo less conversion in the liver, and improve local tissue with minimal elevation of the serum estradiol level.1,3
The vaginal ring (Estring) delivers the lowest systemic estradiol level—approximately 5 to 10 μg of estradiol daily. Femring delivers more estradiol daily and requires the addition of progesterone in women who have an intact uterus.
Local estrogen formulations were compared and reviewed in a systematic Cochrane meta-analysis of 19 trials that included 4,162 women.5 Vaginal cream, tablets, and rings were all equally effective in treating symptoms of atrophy. One trial found that cream (conjugated equine estrogen) increased the risk of uterine bleeding, breast pain, and perineal pain, compared with vaginal tablets.
Newer estrogen formulations include topical and transdermal patches, gels, lotions, and sprays (TABLE 1), all of which are systemic. They are effective in the treatment of vasomotor symptoms and vaginal atrophy.
Topical estrogen formulations—a rundown of local and systemic options
|Product||Dosing||Administration||Source of active ingredient|
|Vagifem||25 μg of estradiol||One tablet intravaginally daily for 2 weeks; then, twice weekly||Synthesized from soy|
|Premarin||0.5 g (0.625 mg/g of conjugated estrogen)||Insert 0.5 g daily for 3 weeks; then, twice weekly (Note: Dosage can be increased to 2 g daily but this may require progesterone supplementation)||Urine of pregnant mares|
|Estrace||0.1 mg of estradiol/g of cream||Insert 0.5 g daily for 1 or 2 weeks; then, twice weekly||Synthesized from soy and yams|
|Estring||2 mg (delivers 6–9 μg of estradiol daily)||Insert 1 ring intravaginally for 3 months||Synthesized from Mexican yams|
|Femring||Delivers 0.05 mg–0.1 mg of estradiol daily||Insert 1 ring intravaginally for 3 months||Synthesized from soy|
|Estraderm||Delivers 0.05 mg or 0.1 mg of estradiol daily||Apply patch twice weekly||Synthesized from Mexican yams|
|Estradiol (generic)||Delivers 0.05 mg or 0.1 mg of estradiol daily|
|Esclim||Delivers 0.025 mg, 0.0375 mg, 0.05 mg, 0.075 mg, or 0.1 mg of estradiol daily|
|Vivelle, Vivelle-Dot||Delivers 0.025 mg, 0.0375 mg, 0.05 mg, 0.075 mg, or 0.1 mg of estradiol daily||Synthesized from Mexican yams|
|Climara||Delivers 0.025 mg, 0.0375 mg, 0.05 mg, 0.06 mg, 0.075 mg, or 0.1 mg of estradiol daily||Synthesized from soy|
|Alora||Delivers 0.025 mg, 0.05 mg, 0.075 mg, or 0.1 mg of estradiol daily|
|Menostar||Delivers 0.014 mg of estradiol daily||Apply patch once weekly (Note: Indicated only for prevention of osteoporosis)|
|CombiPatch||Delivers 0.05 mg or 0.14 mg daily of estradiol plus 0.05 mg or 0.25 mg daily of norethindrone||Apply patch twice weekly||Synthesized from soy (estradiol) and Mexican yams (norethrindrone)|
|ESTROGEN LOTION, GEL|
|Estrasorb (lotion)||Content of two pouches delivers 0.05 mg daily of estradiol||Apply one packet to each leg daily||Synthesized from soy|
|EstroGel (gel)||1.25 g (0.75 mg of estradiol)||Apply one pump to arm once daily|
|Divigel (gel)||0.25 g, 0.5 g, or 1 g of 0.1% estradiol||Apply one packet to upper thigh daily|
|Elestrin (gel)||0.87 g (0.52 mg of estradiol)||Apply one pump to arm once daily|
|Evamist||1.53 mg of estradiol in each spray||Apply 1-3 sprays to forearm daily|
|Source: Cirigliano M. Bioidentical hormone therapy: a review of the evidence. J Womens Health (Larchmt). 2007;16:600–631.|