Who needs vaginal estrogen?
It is interesting what we are taught about our bodies. We learn about getting our first period. We talk about pregnancy. There’s education about birth control and breastfeeding. But we don’t talk a lot about menopausal changes. And that means that some of the symptoms can be a huge surprise to women. Vaginal dryness. Bladder infections. Painful sex. All of these symptoms can be a part of menopausal issues. If they happen, they are all treatable. This transition in our lives is so much easier if you know what you might expect. So, what is vaginal estrogen, and who needs it?
Menopause
You are technically in the menopausal period of your life when you haven’t had a period in more than 12 months (barring other medical conditions). This happens when the ovaries stop producing enough estrogen to cause menstruation. (read more about menopause here https://www.menopause.org/for-women/expert-answers-to-frequently-asked-questions-about-menopause/menopause-faqs-understanding-the-symptoms). But, it also means that you can no longer get pregnant. Estrogen levels usually start to decline in our 40s until we hit menopause in our early 50s. There is a huge range in the symptoms that different women experience. Some women experience no symptoms. Some women get horrible symptoms. However, symptoms can start when you are perimenopausal- this is when you are still getting periods (although they may be lighter or irregular), but your estrogen levels are declining. Symptoms may start several years after menopause. This all means that I often see women with these issues when they are in the 40-60-year-old range.
Common symptoms during menopause
There are lots of different types of symptoms that are caused by the decline in estrogen levels. Of course, some women get all of these symptoms, others may just have a few of the symptoms. The most common symptom that we associate with menopause is hot flashes. These happen at all different times of day and may be severe enough that they wake you from sleep. This can make it hard to get a good night’s rest and may leave you feeling irritable and tired. You can also have pain and discomfort. Your muscles may ache. Your joints may hurt. You may even get migraines. (read more here https://www.nhs.uk/conditions/menopause/symptoms/).
The genital tissues and bladder tissues are sensitive to estrogen levels. The symptoms caused by menopause in these tissues are lumped together and called the “Genitourinary Syndrome of Menopause.” https://www.uptodate.com/contents/genitourinary-syndrome-of-menopause-vulvovaginal-atrophy-clinical-manifestations-and-diagnosis#:~:text=Genitourinary%20syndrome%20of%20menopause%20(GSM,that%20occur%20in%20menopausal%20patients.
Genitourinary Syndrome of Menopause
This name is a mouthful. We used to call these symptoms vaginal atrophy but then renamed it to be more inclusive of bladder issues. So this syndrome includes all the changes created by a lack of estrogen in the genitals (vulva and vagina) and the urinary tract (bladder and urethra). These symptoms can include:
- Vaginal dryness, burning, and irritation
- Vulvar itching and irritation
- Vaginal discharge
- Pain with peeing
- Needing to pee all the time
- Lots of urinary tract infections
- Pain with sex
- Vaginal dryness
About 50% of all menopausal women will get these symptoms. And of these women, half of them are never treated for these symptoms. Even though these symptoms dramatically impact quality of life and really bother the women experiencing them. These are all symptoms of menopause and worth discussing with your health care provider. And these symptoms are worth being treated.
Why vaginal estrogen
If your symptoms are all related to Genitourinary Syndrome of Menopause, you really only need to treat the tissues of the vagina. So you don’t need to start an oral form of estrogen. This means you could try a lubricant for painful sex and dryness. There are many different lubricants on the market. In general, there are three types- water-based, silicone based, and oil based. Water-based lubricants work well and wash away quickly. They can be used with condoms and any toys. Silicone-based lubricants last longer, are good for sensitive skin, can be used with condoms but may degrade toys. Oil-based lubricants are also long-lasting but can’t be used with condoms and may increase the risk of yeast infection. If the vaginal dryness is bothersome, you could try a vaginal moisturizer. I often recommend Hyalo-gyn but there are lots of different moisturizers available.
If these therapies don’t work, it is time to try vaginal estrogen. Vaginal estrogen is a form of estrogen that is placed in the vagina. It comes in a cream, a pill, a suppository, and a ring. The ring can be left in the vagina for 3 months at a time, the other forms are usually placed in the vagina twice a week. Estrogen that is placed in the vagina has fewer possible risks than estrogen that is taken by mouth or via a patch. Studies have shown that blood levels of estrogen stay in the menopausal level when it is given through the vagina. And this means that the increased risk of taking it is incredibly low.
Vaginal estrogen improves the blood flow to the vaginal and vulvar tissues.
Since estrogen improves sensation in these tissues as well as vaginal lubrication. While it decreases irritation and the burning feeling. Vaginal estrogen is FDA approved for the treatment of genitourinary symptoms and pain with sex. It is often used to treat recurrent bladder infections and bladder symptoms too, although this use is technically off-label if it isn’t happening with vaginal symptoms. Since vaginal estrogen helps with so many of the symptoms in this area, it is often where I will start. There are two other treatments for these symptoms. One is a pill called ospemifene that acts as a selective estrogen receptor modulator. It works on some tissues that are estrogen sensitive like the vagina. The other is vaginal DHEA. This treatment increases the levels of vaginal estrogen and testosterone.
However, vaginal estrogen should not be used in women with unexplained infections or vaginal bleeding. But, we will use it in some women who have had a estrogen-dependent tumor (like a breast cancer) but only if their cancer doctor agrees. And this posting really focused on vaginal estrogen. If you are having more symptoms like hot flushes, you might be a candidate for oral or patch-form estrogen. But that is a topic for another day.
NAMS 2022 HRT position statement
NAMS 2020 Genitourinary Syndrome of Menopause position statement
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