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Vaginal Estrogen – When Less Is More

If there’s one thing I’ve learned over the years when it comes to medications, it’s this – more is not necessarily better. You can have too much of a good thing, and less can sometimes be more.

Certainly that’s been the mantra when it comes to hormone replacement in menopause. Since the WHI findings were released in 2002, we’ve all been going lower and lower with estrogen dosing, and finding that, for many women, it’s more than enough to treat the symptoms.

Now, a new low dose formulation of vaginal estrogen, Vagifem 10 ug, approved in Dec 2009, has hit the market. I have to say that I am thrilled to have this option for my patients.(I know, some of you are in shock that I would actually be talking favorably about a new drug, but hey, when they get it right, they get it right.)

Research has shown that vaginal 10 ug estradiol tablets are effective in treating symptoms of postmenopausal vaginal atrophy and dryness. While the previously marketed 25 ug vaginal estradiol preparation was superior in some measures when the two were compared, the lower dose may be all that some women need.

Why go lower dose? After all, the 25 ug vaginal estradiol dose is pretty darned low, and does not typically lead to elevation of estrogen levels above the normal postmenopausal background after the first two weeks of use. But I have had occasional patients complain of breast tenderness in those first two weeks of more intense Vagifem use (you use it once a night in the beginning, then twice a week after that) and even one or two for whom the use of vaginal estrogen triggered a headache. I’ve been anxiously waiting for the lower vaginal dosing ever since the research was published on its relative efficacy. Glad to see it’s finally here.

Medicare recently moved this Vagifem off its preferred formulary, which has been a real problem for a lot of my older patients who no longer can afford it, even though they prefer it over the vaginal creams. As do I, since absorption is probably lower with the vaginal tablets than the creams. (The vaginal ring had the lowest systemic absorption until now, but unfortunately it is too large for some women to use.)  Fortunately, we can customize the cream to a lower dose by just using less of it.

Of course, some women, particularly those at increased risk for breast cancer, are uncomfortable with estrogen in any form. For these women, there are over the counter vaginal moisturizers. And a good  lubricant is helpful for sexual activity, even for some women using vaginal estrogen.

The big question is, will this new low dose vaginal estrogen be low enough for women using aromatase inhibitors? These women suffer terribly from vaginal dryness, but even vaginal estrogen may be too much for them, since we aim for serum estrogen levels of zero in this group. It’s an important question that will need to be studied before any of us are comfortable using even this lower dose preparation in this important subgroup of postmenopausal women.

*This blog post was originally published at The Blog that Ate Manhattan*

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