Overcoming resistance and barriers to the use of local estrogen therapy for the treatment of vaginal atrophy

Figures & data

Table 1 Symptoms and signs of estrogen deficiency and vaginal atrophy^4,8,10

System	Symptoms	Physical and functional changes
Genital	Dryness	Thin, pale, and dry vulvar and vaginal tissue
	Dyspareunia	Inflammation of vaginal walls
	Itching	Vaginal petechiae, purpura, or ecchymoses
	Discharge	Loss of rugal folds; obliteration of fornices
	Pain	Shortened, narrowed vagina
		Loss of vaginal elasticity
		Diminished vaginal blood flow
		Reduced sebaceous secretions
		Loss of labial fat pad
		Pendulous labia majora; less distinct labia minora
		Shortening of prepuce and excessive exposure of clitoris
		Pubic hair loss
		Abnormal vaginal maturation index (↓ superficial layer cells; ↑ Parabasal and intermediate cells)
		Increase of vaginal pH above 5.0
		Increased susceptibility to trauma, infection, and pain
		Minor lacerations (peri-introital/posterior fourchette)
Urinary	Frequency	Mucosal thinning (urethra, bladder)
	Urgency	Urethral shortening
	Burning with urination	↓ Periurethral collagen
	Incontinence	Urethral caruncle
	Recurrent urinary tract infection	Urethral prolapse
		Cystocele
		Sphincter weakening
		↓ Bladder storage capacity
		↑ Post-void residual urine volume
		↑ Uninhibited detrusor muscle contractions

Notes: ↓, decreased; ↑, increased.

Figure 1 Approach to treatment of vaginal atrophy.^9,11

^†Undiagnosed abnormal uterine bleeding, breast cancer (except in appropriately selected patients being treated for metastatic disease), estrogen-dependent neoplasia, deep vein thrombosis or pulmonary embolism, arterial thromboembolic disease within the past year, liver disease/dysfunction, pregnancy, or hypersensitivity to estrogen therapy.^{35 ‡}Concomitant progestogen therapy is recommended in women with an intact uterus and who are receiving systemic estrogen therapy to prevent endometrial proliferation and adenocarcinoma.¹²

Notes: *Use in patients with hormone-dependent cancer has not been well studied; risk/benefit should be determined on a case-by-case basis.⁹

Table 2 Commercially available local estrogen therapies

Formulation	Product	Benefits	Limitations	Dosing
Vaginal cream	Estrace^® (estradiol, 100 mcg/g; Warner Chilcott, Rockaway, NJ)^Citation21 Premarin^® (conjugated estrogens, 625 mcg/g; Pfizer, New York, NY)^Citation22	Dosing flexibility; inexpensive	Poor dose control/ potential for overdosing; complex regimen (adherence); potential for leakage	Estrace: 2–4 g/day × 1 or 2 weeks, gradually reduced to half initial dose × 1 or 2 weeks; 1 g 1–3 times weekly for maintenance Premarin: 0.5–2 g/day for 21 days; off for 7 days; repeat or 0.5 g twice weekly
Vaginal ring	Estring^® (estradiol, 7.5 mcg/day; Pfizer)^Citation23	Fixed-dose/minimal risk for overdose; infrequent dosing	May fall out; may be difficult to insert/remove; may affect sexual intercourse	Replace ring every 3 months
Vaginal tablet	Vagifem^® (estradiol, 10 mcg*; Novo Nordisk A/S, Bagsvaerd, Denmark)^Citation24	Fixed-dose/minimal risk for overdose	Adherence to regimen	Vagifem: 1 tablet daily × 2 weeks; twice weekly thereafter

Note:

* The 25 mcg vaginal tablet, discontinued July 2010, was replaced with the 10 mcg tablet.

Table 3 Potential solutions to common barriers to identification and treatment of vaginal atrophy

Barrier	Potential solution
Patient uncomfortable discussing vaginal atrophy	Initiation of regular discussions of vaginal health during preventive health evaluations; assure patient that vaginal atrophy is common and treatable; use the 5 A’s* of behavioral counseling^Citation41 to guide discussion
Patient hesitant to use estrogen therapy	Education about benefits and risks; highlight differences between standard-dose therapies, systemic therapies, and low-dose local therapies
Resistance to use of local therapies	Individualization of therapy with which the patient is most comfortable; set expectations regarding use/effects; arrange appropriate monitoring/follow-up

Note:

* Assess, Advise, Agree, Assist, Arrange.

SturdeeDWPanayNInternational Menopause Society Writing GroupRecommendations for the management of postmenopausal vaginal atrophyClimacteric201013650952220883118

 PubMed Web of Science ®Google Scholar

ReimerAJohnsonLAtrophic vaginitis: signs, symptoms, and better outcomesNurse Pract2011361222821150811

 PubMedGoogle Scholar

LaraLAUsecheBFerrianiRAThe effects of hypoestrogenism on the vaginal wall: interference with the normal sexual responseJ Sex Med200961303919170834

 PubMed Web of Science ®Google Scholar

DenizGAntoineCLiebensFCarlyBPastijnARozenbergSTreatment of premature menopause in breast cancer patientsActa Chir Belg2007107326326617685250

 PubMed Web of Science ®Google Scholar

Mac BrideMBRhodesDJShusterLTVulvovaginal atrophyMayo Clin Proc2010851879420042564

 PubMed Web of Science ®Google Scholar

North American Menopause SocietyMenopause Practice: A Clinician’s Guide4th edMayfield Heights, OHThe North American Menopause Society2010

 Google Scholar

North American Menopause SocietyThe 2012 hormone therapy position statement of: The North American Menopause SocietyMenopause201219325727122367731

 PubMed Web of Science ®Google Scholar

BachmannGSantenRJClinical manifestations and diagnosis of vaginal atrophyBasowDSUpToDateWaltham, MAUpToDate2011 Available from: http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-vaginal-atrophy?source=search_result&search=Clinical+manifestations+and+diagnosis+of+vaginal+atrophy&selectedTitle=1-45Accessed August 28, 2012

 Google Scholar

BondSHortonLSManagement of postmenopausal vaginal symptoms in womenJ Gerontol Nurs201036737

 Web of Science ®Google Scholar

RoySCaillouetteJCRoyTFadenJSVaginal pH is similar to follicle-stimulating hormone for menopause diagnosisAm J Obstet Gynecol200419051272127715167829

 PubMed Web of Science ®Google Scholar

BrunnerRLAragakiABarnabeiVMenopausal symptom experience before and after stopping estrogen therapy in the Women’s Health Initiative randomized, placebo-controlled trialMenopause201017594695420505547

 PubMed Web of Science ®Google Scholar

WhitlockEPOrleansCTPenderNAllanJEvaluating primary care behavioral counseling interventions: an evidence-based approachAm J Prev Med200222426728411988383

 PubMed Web of Science ®Google Scholar