Sexual Health

TRANSCRIPT

*Hello, I am Dr. Sukhpreet Patel, an MD ObGyn, a Menopausal Health advocate, a Post Menopausal woman, and the founder of MenopauseWize. And this session is all about using vaginal estrogen for the symptoms of menopause aka the Genitourinary syndrome of menopause

Before we begin please spend a few minutes reading the disclaimer by pausing this recording. And I'd also like to specify that I have no affiliation or association with any brand mentioned in this recording.

Vaginal discomfort, painful intercourse, feeling the urge to pee all the time, waking up at night to pee, and recurrent UTIs… are some of the symptoms of the genitourinary syndrome of menopause

- and we have discussed a few options like vaginal lubricants and moisturizers in some other recordings. All of these symptoms are caused by one central event - the lack of estrogen in these tissues. 

So what if instead of lubricants and moisturizers which only take care of the symptoms on the surface, we take care of the root cause of the problem by adding some estrogen back into the vagina? I know, many of us believe that hormones and hormone replacement therapy or HRT is bad for us - and I will discuss that in future posts. But, here I am talking about delivering estrogen directly into the vagina in such a low dose that it takes care of all the vaginal symptoms without changing the blood estrogen levels so that you don't have to stress about the so-called bad effects of hormone therapy?

But, is vaginal estrogen for everyone? Like for every prescription drug, there is a group of women who should not use vaginal estrogen - First, women who don't have a prescription - and I know this sounds odd considering that it is a prescription medicine - but I am aware that in certain parts of the world including where I come from procuring a prescription drug without a prescription is NOT very difficult - BUT please ladies, please visit your physician and check all the boxes before using it.

Some other contraindications for vaginal estrogen include A. women with undiagnosed vaginal or uterine bleeding - which means those who have some abnormal bleeding after menopause and have not had it checked out. B. those with cancers that are estrogen-dependent. C. Those with an increased risk of thrombosis or forming clots, liver disease, and pregnancy (of course) Even though no studies so far have proven the association of vaginal estrogen with the formation of clots or damage to the liver, this still remains a grey area because of oral estrogen's bad reputation. This basically means low-dose vaginal estrogen is a great option for a vast majority of post-menopausal women.

Coming to the formulations available in the market, Low-dose vaginal estrogen is available in various forms including creams, tablets, and rings BUT…

 I am going to focus on creams for now since this is the only option that is currently available in India. And besides, it is a preferable method for many reasons. Before discussing recommended doses I would like to stress the importance of a physical examination before initiating treatment. Firstly, to ensure that there is no other condition that is the cause for your symptoms because if that is the case vaginal estrogen is not going to help you, and in fact, it may even be harmful.  and secondly, because your physician will be able to decide the right dose for you after an examination. So, vaginal estrogen therapy is broken up into 2 parts - the initial therapy which is for repair of the vagina and this requires daily application followed by maintenance doses 1 to 3 times a week. And maintenance means that if you stop using it the vagina can get dry again - just like moisturizing your hands. Now, what dose works for each woman differs and trial and error under the supervision of a licensed physician is the best way to tweak the actual dose that works for someone.

There are 2 forms of estrogen cream available in India - Estriol, available as Evalon cream and Conjugated estrogen or Premarin vaginal cream. In general, there are different kinds of estrogen and estriol is a less potent estrogen compared to conjugated estrogen. Since it is generally recommended to stay on the lowest dose of vaginal estrogen that can eliminate a woman's symptoms, if someone has been using estriol cream and it works for them, they may consider continuing to use it under the supervision of your physician - remember, estriol cream is also a prescription drug. But if it isn't working for someone, they may consider switching to the more potent conjugated estrogen or Premarin vaginal estrogen cream.

Before I describe how to use this cream it is important to understand the basic female anatomy. As most of us are aware, women have 3 openings down there - starting from front to back - they are the urethra through which we pee, the vagina through which we menstruate and have vaginal sex, and the anus through which we poop. Protecting the vagina and urethra are the 2 labia or lips and in front of the urethra is the clitoris - stimulation of which is responsible for orgasm in most women. 

Now, typically vaginal estrogen Cream is available in a tube - one needs to squeeze it into the accompanying reusable applicator up to the dose recommended, insert it in the vagina and then push the plunger to apply it. BUT

one of the big problems that women often face is inserting the applicator. Once dryness has set in, inserting the applicator can become an ordeal on its own. Besides, having to wash and dry and even hide the applicator in a household can be a pain. But here are a few things that you can do to get around these issues...

Firstly, you don't need to apply the cream right at the top of the vagina - estrogen receptors are located mainly in the lower third of the vagina - so there is no need to go through unnecessary discomfort in trying to insert the applicator all the way into the vagina.

Secondly, you can use your finger to apply the cream -  apply the approximate dose that you require along the length of your finger and insert it in the vagina and rotate your finger around - and don't worry if the dose isn't exact - as long as you have a rough estimate by measuring with the applicator a couple of times.

If you aren't comfortable inserting your finger in your vagina because of extreme dryness, start with just a teeny bit of estrogen on the opening of the vagina for a week or so, and then try inserting it inside. 

Another big advantage of the cream as opposed to other methods of estrogen delivery is that one can apply it in problem areas such as the fork of the vagina which is the most common area for women to get injuries in the form of cuts during vaginal intercourse. And applying a dot over the urethra and clitoris can reduce your urinary symptoms and enhance your orgasm experience, respectively. 

But one scary part of using vaginal estrogen is the boxed warning on the package inserts of these products. You see, the FDA requires that all products that contain estrogen have warnings that pertain to the intake of ORAL estrogen based on an old and now outdated study called the WHI - which is a long conversation for another time. These risks include endometrial and breast cancer, cardiovascular disorders, and dementia. Unfortunately, these risks remain on the label despite no evidence to support that vaginal estrogen has the same effects. In fact, the North American menopause society filed a petition against this warning in 2018 asking the FDA to modify the label for low-dose vaginal estrogen products and they believe that this warning quote-unquote "unnecessarily frightens women and keeps them from much-needed treatment". But the warning persists since according to the FDA, all products that contain ESTROGEN need to have this. Why am I telling you about this? So that you understand why that warning is on the box when you make an informed decision about using low-dose vaginal estrogen with your doctor. 

Coming to the side effects of low-dose vaginal estrogen. Like all prescription drugs, it too has some side effects but it's common to have no side effects or only minor ones which include vaginal discomfort or itchiness, discharge, breast pain, and headache which usually settle down once your body gets used to it or you cope with it. But you could experience other side effects as well that are mentioned on the package insert. You should see your physician to discuss the side effects that you experience.

Like with everything, low-dose vaginal estrogen also has its own set of pros and cons. Besides taking care of your symptoms, using the cream form has the advantage of not changing your blood estrogen levels. Also, the cream form makes it easy to manipulate the dose so that you can use the lowest possible dose that works for you. On the other hand, estrogen cream can be messy - but come on ladies we did go through monthly discharge and periods for decades! One way to avoid the messiness is to apply it at bedtime

Also, one has to keep using it as a maintenance dose to keep the symptoms from recurring but according to the Menopausal Society, one can use it quote-unquote "with appropriate clinical follow up, for as long as bothersome symptoms are present." which means you can stay on it as long as you want to but as long as you continue to follow up with your physician!

That's it on vaginal estrogen! If you have any questions or concerns that you'd like me to address, feel free to join the MenopauseWize community on MenopauseWize.com - an online community of credible menopause experts and peers. 

Unlike other social media platforms, we are a free and safe space for women to learn and share their menopause experiences and also receive special discount codes. After all, we want to thrive - not just survive through perimenopause, menopause, and beyond…because we are Menopausewize!

#menopausewize #menopause #perimenopause #vaginalestrogen #vaginaldryness #womenover40 #womenover50

*This video is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease, and those seeking personal medical advice should consult with a licensed physician. Always seek the advice of your doctor or other qualified health provider regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or heard on this channel. If you think you may have a medical emergency, call 911 or go to the nearest emergency room immediately. No physician-patient relationship is created by this video or its use. Neither Sukhpreet Patel, MenopauseWize nor its employees, nor any contributor to this video, makes any representations, express or implied, with respect to the information provided herein or to its use.