Vol 83, No 10 (2012)

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Local estrogen therapy – clinical implications – 2012 update

Tomasz Rechberger, Beata Kulik-Rechberger, Aleksandra Bartuzi, Marta Kokot-Kierepa
Ginekol Pol 2012;83(10).


With increasing longevity in Poland, women can now expect to live around 40% of their lives after menopause, and there is a growing desire for older women to preserve their vitality, sexual function and quality of life. The most common urogenital symptoms associated with menopause are dryness, followed by irritation or itching, and discharge, with a substantial number of post-menopausal women also being affected by dysuria. These symptoms are the result of vaginal atrophy, which is in turn caused by reduced transudation through the vaginal epithelium and reduced cervical gland secretions resulting from post-menopausal estrogen depletion. Vaginal atrophy generally occurs 4–5 years after the last menstrual period and progressively increases in prevalence in the subsequent years. Importantly, vaginal atrophy is strongly associated with sexual dysfunction, and lower urinary tract symptoms, such as frequency, urgency, nocturia and dysuria, as well as incontinence and recurrent infection are reported more frequently in the presence of vaginal atrophy. Those symptoms, apart from being bothersome for the patients also negatively impact their quality of life. Consequently, before irreversible changes occur, early detection and treatment of vaginal atrophy should be implemented. Estrogen therapy is the most commonly prescribed treatment. Estrogens restore the cytology, pH and vascularity of the vagina, resulting in symptom resolution for the majority of treated women. Because vaginal atrophy symptoms tend to occur later than vasomotor symptoms, many women do not necessarily require or wish to take systemic estrogen treatment if their symptoms are restricted to the urogenital tract. Vaginal estrogen products deliver estrogen locally to vaginal tissues with little or no systemic absorption and provide an effective alternative to systemic estrogen therapy for these women. Various vaginal estrogen preparations such as conjugated equine estrogens, estradiol and estriol vaginal creams, a sustained-release intra-vaginal estradiol ring and a low-dose estradiol and estriol tablets are useful therapeutic options in the treatment of this condition. Moreover, a low dose treatment with a minimised systemic absorption rate may be considered in women with a history of breast cancer and associated severe vulvovaginal atrophy. It should be mentioned that vaginal lubricants once applied on a regular basis may also be effective in alleviating the symptoms of vaginal atrophy and should be offered to women wishing to avoid the use of local vaginal estrogen preparations and in cases where local estrogen therapy is contraindicated. Vaginal dehydroepiandrosterone (DHEA), vaginal testosterone, and tissue selective estrogen complexes are new, emerging therapies; however, more clinical studies are necessary to confirm their efficacy and safety in the treatment of postmenopausal vulvovaginal atrophy.

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