image by: HWN

HWN Suggests

The Magic of Hormones

It’s TOTALLY safe for essentially all women. In fact, there are very few woman >50 who I wouldn’t recommend the use of local vaginal estrogen. Occasionally I need to pick up the phone and talk to her cancer doctor to discuss the fine print. There is no data. NO DATA. That local vaginal estrogen causes cancer, cardiovascular problems, stroke, dementia or any other issues. In fact, studies with over 18 years of observational show safety. Even studies in women who have gynecologic cancers have no issues using local vaginal estrogens. I prescribe and encourage this therapy in my patients with breast cancer, a family history of breast cancer, and those who are worried about breast cancer.

read full article

Featured

 Treating the Incredible Shrinking Vagina

Vaginal estrogen, which is available as either estradiol or conjugated equine estrogens, are considered the gold standard to replace the estrogen your body is no longer making after menopause. They come in a wide range of formulations including creams, a vaginal ring, vaginal tablets and gel caps. Vaginal estrogen is very safe and not associated with breast cancer or stroke when used as recommended.

Articles of Interest

Is Vaginal Estrogen Safe If I had Cancer or a Heart Attack?

Single study of low-dose vaginal estrogen did not show increased risk of cancer recurrence. Systemic absorption of vaginal creams, pills, and rings is very low (lowest for Estring and Vagifem) Consult with patient’s oncologist before starting vaginal estrogen in patient with history of ER/PR+ breast cancer, more likely to be safe if on tamoxifen and less likely to be safe if on aromatase inhibitor.

By the way, doctor: Is vaginal estrogen safe?

When low-dose estrogen is applied vaginally, you generally don't need a progestin to offset its potentially carcinogenic effects on the endometrium. Low-dose vaginal estrogens shouldn’t spur any significant growth of endometrial cells when used for up to a year.

Estrace vs. Premarin Creams for Menopause Symptoms

Estrace is a vaginal cream that contains a lab-made form of one type of estrogen, called estradiol. Your body uses this estradiol in a similar way to naturally-produced estrogens. Estrace is available as a brand name and generic product. It comes in a tube that contains 0.01% of the active ingredient. What is Premarin cream? Premarin is also a vaginal cream, but it contains conjugated estrogens. This means it’s a mixture of a few types of estrogen. These estrogens are derived from a natural source: the urine of pregnant horses. So if you typically avoid using animal products, let your healthcare provider know. Unlike Estrace, Premarin doesn’t have a generic available yet. Each tube contains 0.625 mg of estrogens in every gram of cream.

How Safe Are Low-Dose Estrogen Vaginal Creams Like Estrace?

The NWHN believes that, as the research currently stands, it appears that vaginal estrogen is a safe and effective treatment for vaginal discomfort due to menopause. Additionally, women with a personal or family history of breast cancer often think they are not candidates for vaginal estrogen. These women need adequate counseling on the safety of vaginal estrogen for them to make an informed decision. Advocate and inform your patients so they are not a GSM statistic.

Is Vaginal Estrogen Safe?

The key to remember here is that this is topical vaginal estrogen, which is simply a cream that you use in the vagina. Inevitably, patients are wary of the cream because of the word "estrogen." They worry about their breast health and their cardiac health due to information they've read or media reports. But what they're really thinking about is hormone replacement therapies (HRT) that use estrogen as well as the results from the famous Women's Health Initiative study published in 2002 that raised questions regarding estrogen's safety. But here's the thing you need to keep in mind: in hormone replacement therapy, estrogen is delivered orally—meaning, in pill form. Pills and creams are very different. Their absorption in the body is different. Medications that you take by mouth get processed in your abdomen and usually in your liver and by your kidneys, and then the rest of your body "sees" it. If you take an estrogen pill, your breast tissue would see it, your heart sees it, your bones see it, and, eventually, every other tissue sees it. But if you use a local cream, just in the vagina, it's only absorbed where it's applied. So, yes—it's safe to give supplemental estrogen straight to the vagina. It does not put patients at an increased risk for breast cancer. It does not put them at increased cardiac risk. Like any medication, however, a patient can experience side effects.

Vaginal Estrogen Therapy Use and Survival in Females With Breast Cancer

Results of this study showed no evidence of increased early breast cancer–specific mortality in patients who used vaginal estrogen therapy compared with patients who did not use HRT. This finding may provide some reassurance to prescribing clinicians and support the guidelines suggesting that vaginal estrogen therapy can be considered in patients with breast cancer and genitourinary symptoms.

Low-dose vaginal estrogen, CVD and cancer: Is there a risk?

A new prospective analysis from the Nurses’ Health Study (NHS) indicates that, despite its “black box” warning, low-dose vaginal estrogen does not pose an increased risk of cardiovascular disease (CVD) or cancer. However, Dr. Manson said the US Food and Drug Administration has made no commitment to remove the boxed warning, despite the lack of evidence for it – and growing evidence that refutes it. “The FDA should revisit its decision about the product labeling and undertake a comprehensive assessment of the evidence, given the importance of this issue for women’s health and well-being,” she said.

Revaree® vs. Vaginal Estrogen Cream: Is Hyaluronic Acid an Effective Treatment for Vaginal Dryness?

“Findings suggested that Revaree is not inferior to estrogen cream and may be a great option for anyone looking to manage the symptoms of vaginal dryness, without hormones,” Dr. Dweck explains. “This is especially important for those who have to or prefer to avoid products containing hormones when managing their vaginal symptoms.”

Resources

Alloy (Estradiol Vaginal Cream)

Localized, topical estradiol cream to provide effective relief for vaginal dryness, itching, burning and the prevention of frequent UTIs.

BreastCancer.org

Many people — both healthcare providers and people with a breast cancer diagnosis — have concerns about vaginal estrogen. The worry is that, even in low doses, vaginal estrogen might increase the risk of recurrence (the cancer coming back) in people with a history of hormone receptor-positive breast cancer. However, studies show that the amount of estrogen the body takes in from vaginal treatment is tiny, and research, which continues to grow, suggests that there's no difference in how long people are living if prescribed vaginal estrogen after breast cancer.

Estrace ( Estradiol Vaginal Cream)

Each gram of ESTRACE (estradiol vaginal cream USP 0.01%) contains 0.1 mg estradiol in a nonliquefying base containing purified water, propylene glycol, stearyl alcohol, white ceresin wax, mono- and di-glycerides, hypromellose 2208 (4000 cps), sodium lauryl sulfate, methylparaben, edetate di-sodium and tertiary-butylhydroquinone

Estriol Vaginal Cream (Compounded)

Estriol contains the natural female hormone estriol. Unlike other estrogens, estriol is short acting since it has only a short retention time in the nuclei of endometrial cells. It substitutes for the loss of estrogen production in menopausal women and alleviates menopausal symptoms.

Premarin (Conjugated Horse Estrogens)

Premarin (conjugated estrogens) Vaginal Cream is used after menopause to treat menopausal changes in and around the vagina and to treat moderate to severe painful intercourse caused by these changes.

Winona (Estradiol Vaginal Cream)

Active Ingredient(s): Estradiol USP Inactive Ingredient(s): C12 - 15 alkyl benzoate, caprylic/capric triglycerides, cetyl alcohol, ethylhexylglycerin, glycerin USP, glyceryl stearate, hydroxyethyl acrylate/sodium acryloyldimethyl taurate copolymer, oleic acid, olive oil, PEG-100 stearate, polymethylsiloxane, purified water, stearic acid, trolamine NF, and vitamin E acetate.