Estrogen Treatment of the Vagina

Estrogen works to treat the vaginal changes that occur in menopause. For some women there are only minor symptoms, others have bladder symptoms, recurrent urinary tract infections, stress incontinence, painful sex, irritating dryness or itching. Women who have these symptoms in menopause, and now is more accurately called genitourinary syndrome of menopause.  It is commonly caused by the thinning of the vaginal walls due to menopausal changes. For the most part your gyno can tell by looking but are even pap tests to determine if this is the diagnosis, although your gyno can hear your complains and with the exam give you a diagnosis.

Generally gynos have recommended nonhormonal moisturizers such as coconut oil, or products such as Replens if you have mild symptoms, and estrogen therapy as the treatment of choice for this condition,  and now we have the new painful sex treatment ospemifene, or Osphena. Ospemifene is a  selective estrogen receptor modulator that makes vaginal tissue thicker and less fragile, resulting in a reduction in the amount of pain women experience with sexual intercourse. Osphena is also a systemic treatment that likely has positive effects on your bones as well as breast cancer prevention component. Although gynos estimate that virtually all women remaining sexually active into their post menopausal years will have this complaint if not treated by hormone therapy, over half never even bring it up at a medical visit. Of women with genitourinary syndrome in menopause so a great number of women stand to benefit by considering therapy.

Before therapy you need some evaluation: do you have an infection of the vagina, a bladder infection, or perhaps badder dysfunction that can be detected by urodynamics also known as cystometrics. .  Vaginal estrogen treatments are effective for all of the issues that occur with this syndrome. The doses of estrogen given do not cause estrogen blood levels to differ from women without the vaginal estrogen treatment. Women need to be treated for about 3 months for full effectiveness, and there have been rare cases of the medication can cause thickening of the lining of the uterus which would need to be evaluated. Women experiencing unusual vaginal discharge or bleeding need to see their gyno to see if they have this complication.

The boxed warning for ospemifene also states the incidence rates of thrombotic and hemorrhagic strokes (0.72 and 1.45 per 1000 women, respectively) and the incidence rate of deep vein thrombosis (1.45 per 1000 women)."These rates are considered to represent low risks in contrast to the increased risks of stroke and deep vein thrombosis seen with estrogen-alone therapy," the FDA said. Minor side effects can include hot flashes or vaginal discharge.

Making the decision as to whether to take a systemic therapy or to use estrogen therapy is a complex one. Most women will try simple therapies first and do have to consider risks and benefits of alternatives.  Recent web articles have focused on the negative aspects of this therapy, implying that this risk is greater than other therapies.. These articles not only focus on potential risks, but clearly doesn't list percentages of these risks, nor does it do a good job of addressing benefits and or does it do a good job of discussing alternatives and their risks and benefits. As first line in the discussion with your gyno figure out if you indeed need treatment at all. Most women who take therapy are sexually active, but if you aren't and you plan to be, you are still a candidate for treatment. Osphena as a SERM (selective Estrogen Receptor Modulator) has potential benefits on breast tissue and bones. Find out if you have a baseline risk for for blood clots.  All the clinical trials were done without a progesterone, and the risks were very low of lining changes to the uterus. Some physicians may decide to put you on progesterone therapy if you are on Osphena. Even off hormones entirely women have a baseline risk of endometrial cancer. Estrogen therapy used locally is thought to be safer than systemic therapy,for atrophic changes of the vagina and vulva, yet it does have the same package insert risks listed in terms of blood clots and lining changes of the uterus, and thus it's a decision as to which will be best for an individual woman. And for those wanting completely different therapies there are even newer treatments with PRP and vaginal lasers.


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