My gynecologist, Dr. Becky Brightman, weighs in.
Great news this week for women whose lady parts are parched and sometimes feel like the Sahara: A new study is out that will reduce fears that vaginal estrogen will increase your risk of breast cancer or recurrence. Since Dr. Becky Brightman is my gynecologist, I wanted to get the tea from her.
Katie Couric: A big study just came out about vaginal estrogen therapy. What can you tell us about the findings?
Dr. B: This study appeared in the American Journal of Obstetrics and Gynecology on November 6, 2024. This study was a meta-analysis review of over 5,000 studies that examined the use of vaginal estrogen in women with a history of breast cancer. The study looked at the risk of mortality due to all causes, breast cancer mortality, and risk of recurrent breast cancer.
This study found that women with a history of breast cancer who used local vaginal estrogen therapy for the treatment of genitourinary syndrome of menopause did not increase their risk of recurrence and mortality.
What forms of vaginal estrogen therapy are most commonly prescribed?
There are several FDA-approved forms of vaginal estrogen therapy.
- Estradiol and Conjugated Equine Estrogen creams.
- Estradiol vaginal tablets, suppositories.
- Estradiol releasing vaginal rings
- Prasterone-a steroid that is converted into estradiol and testosterone within vaginal cells.
There are generic estradiol vaginal tablets and creams, and they are almost always covered by insurance plans. They are reasonably priced, even when purchased without insurance. Mark Cuban’s online pharmacy has some of the lowest prices for vaginal estrogen and vaginal estrogen tablets. Vaginal rings are very expensive, frequently not covered by insurance, and are difficult to find. Prasterone is also not considered first-line by many insurance companies, and often, an insurance company will provide coverage only if prior options have not proven to be helpful.
While many vaginal products work well in the vagina, I frequently will recommend that my patients also apply a small amount of vaginal cream to the introitus (vaginal opening) This will help maintain skin integrity and thickness, and prevent itching and dryness.
Who will this impact most?
Over 80 percent of postmenopausal women suffer from symptoms of genitourinary syndrome of menopause (GSM). These symptoms include painful intercourse, vaginal dryness, itching, and burning as well as urinary symptoms of urgency, frequency, and pain with urination. Women with GSM are also at increased risk of getting UTIs.
Many oncologists have been wary about prescribing this kind of therapy. Do you think they’ll change?
Sadly, many oncologists hear the word estrogen and the answer is a resounding “NO.” Not all oncologists inquire about symptoms of GSM, and their main focus is on disease-free survival while not necessarily focusing on quality of life, which includes sexual function, preventing urinary symptoms, and reducing the risk of UTIs. I think that many clinicians confuse local vaginal estrogen therapy with systemic hormone therapy (referred to as HRT, MHT, or ET) and don’t realize that vaginal estrogen acts locally in the vagina and not systemically. Vaginal estrogen will not decrease night sweats, hot flashes, and bone loss. All of the clinical trials that evaluated the safety and efficacy of the various types of FDA-approved vaginal estrogens showed that estrogen levels stayed within the menopausal range.
Many healthcare practitioners don’t specifically ask about GSM symptoms, so they’re less likely to suggest vaginal estrogen. While some might consider vaginal moisturizers first-line, in my practice, I consider vaginal estrogen first-line as it is the most effective way to prevent and treat GSM.
If a woman is not presented with vaginal estrogen as an option for her symptoms, she should feel empowered to ask her healthcare provider about the options outlined above.
