Q: Will I need frequent testing if I use localized hormones?

In my practice, I typically ask to see a patient again three months after I've prescribed localized hormones. That's so we can check in to see whether the therapy is addressing the symptoms as we intended. If it's not, I typically look for other underlying causes or try other treatments; I've found these hormone products to be very effective and generally well tolerated.

Once we've found the right therapy, I typically see women annually to update their general health status and see whether treatments are still accomplishing their goals.

If your practitioner is suggesting something more, I'd suggest that you ask for clarification about the kinds of tests and reasons for them.

Q: Will localized estrogen cream be effective for pain?

What you describe is a natural result of the loss of natural estrogen through menopause. There are a number of localized estrogen options, including Estrace and Premarin creams, Vagifem tablets inserted in the vagina, and Estring, which is a ring also placed in the vagina.

The therapeutic dose of Estrace is 1 gram applied to the vagina and vulva two times a week; using less than that will be, as we doctors say, "subtherapeutic," which means it won't have sufficient effect! While the creams are effective when used as prescribed, many of my patients prefer and get more consistent doses from the ring or tablets.

You mention a family history of breast cancer. None of these options is "systemic," which means that they can be used by women with breast cancer risk factors--even by some breast cancer patients. There's a new option, too, that's non-estrogen: Osphena is an oral daily medication that showed "statistically significant improvement" in vaginal and vulvar pain.

Moisturizers and lubricants can also help to increase comfort while a full treatment plan is taking effect.

It takes attention and consistency to regain comfort after being sexually inactive, but I'm sure you'll find it's worth the effort!

Q: Does my partner absorb any of my localized hormones?

Whether you're using a cream, tablet, or ring to add localized hormones to your vagina, your partner is not absorbing any—no more than he did when you were producing your own hormones before menopause. You (and he!) can feel perfectly confident about your use of these products, and your intimacy will benefit from the increased comfort you're likely to experience.

Q: Is Vagifem safe for me after a thrombectomy?

Vagifem is a vaginal estrogen, applied locally. It is safe for someone with your medical history, posing no risk of thrombosis. Only oral estrogen, which enters the system rather than being applied directly to vaginal tissues, poses some risk of thrombosis or clotting.

You might find an earlier blog post about localized estrogen helpful; in it I described the benefits, forms, and cautions for using vaginal estrogen.

Q: Is an estrogen ring or cream a better option?

Vaginal estrogen is the most effective treatment for vaginal atrophy and its symptoms: dryness, itching, irritation, pain with intercourse. There are three low-dose, localized (without systemic absorption) estrogen options: the vaginal ring (Estring), vaginal tablets (Vagifem), and vaginal creams (Premarin and Estrace). I prefer the ring and tablets, because the cream is messy to use and the absorption is somewhat more variable. Studies confirm is no significant or noted changes in circulating blood estradiol levels with the ring and tablet; the creams are more variable and therefore more likely to have transient elevations in estradiol levels. I have many breast cancer patients who use these methods.

Women who are candidates for vaginal estrogen often also consider over-the-counter lubricants and moisturizers. Lubricants make sex more comfortable in the moment, but don't improve or prevent the progression of the atrophy. Vaginal moisturizers give more lasting comfort. Used independent of sex on a continuous basis, usually two times a week, they can help restore moisture to the tissues. The moisturizers can also help restore a more healthy pH, promote elimination of dead cells, and increase moisture in the tissues.

If there are multiple menopausal symptoms, which may include vaginal dryness, systemic estrogen (like Vivelle) might be considered, weighing all health factors in the decision.

Estrogen Where It’s Needed

Okay, so you’ve tried everything. You regularly use a good, natural moisturizer, plus a lubricant during sex. No soaps, sprays, scents, dyes, or synthetic underwear ever touch your bottom. You’re the queen of vaginal hygiene. And still you’re troubled by dry, itching, or inflamed genitals and painful penetration.

What now?

Talk to your doctor about using a localized estrogen product for your vagina. These medicines deliver low dosages of estrogen right where it’s needed: the vagina and vulva. Not only is localized estrogen medication very effective at relieving the discomfort of vaginal inflammation or atrophy, but it also restores natural vaginal lubrication and elasticity. In fact, while it won’t relieve other menopausal symptoms—like hot flashes—low-dosage vaginal estrogen is sometimes more effective in relieving menopausal genital problems than systemic hormone replacement therapies (HRT). Moreover, the dosages are so low, the side effects and complications so negligible, it is often used by breast cancer survivors.

Vaginal estrogen comes in several forms: a cream (used twice a week), or slow-release tablets (used twice a week), or a ring (which needs to be replaced every three months). Don’t, however, confuse the Estring vaginal ring with Femring, which is the high-dosage HRT in a vaginal ring form. (Confusing? It can be.) Your doctor will tailor the amount and frequency of application for the maximum effect at the lowest possible dose. It may also take several weeks for treatment to become fully effective.

A few precautions:

  • Avoid applying your estrogen cream right before intercourse, since your partner can absorb it through his penis. Estrogen rings and tablets are meant to stay in place and don’t have this effect.
  • Continue to use non-hormonal lubricants and moisturizers if necessary.
  • Have regular vaginal intercourse to augment natural lubrication and a healthy vagina.
While localized estrogen may not be the first line of defense against the unpleasant genital changes related to menopause, it’s an important option when simpler methods (like vaginal lubricants or moisturizers) fail.