Among the most common and sometimes most challenging menopausal experiences many women face are the changes that occur on the external genital tissue and intravaginal tissue that can affect urinary function. This is called genitourinary atrophy, most recently coined genitourinary syndrome of menopause. Symptoms can include one or more of the following: vulvovaginal discomfort, itching, burning, tingling, dryness, thinning of tissue, pain, pain with vaginal penetration related to dryness and/or tightness of vaginal opening, postcoital bleeding, vaginal discharge, bladder leakage, and urinary incontinence.
These symptoms can affect comfort and quality of life as it impacts women's sex lives, their confidence, their partner relationship and their social life.
There are many options to address these genitourinary atrophic changes and symptoms. The most studied and effective is vulvovaginal estrogen. This is a safe treatment if used as and when prescribed, and very different than systemic estrogen/progestogen treatments. There are some specific issues related to patients with a history of breast cancer; however, even then it is only the Premarin and Estrace creams that are best not to use. Vulvovaginal estriol cream, the estrogen ring and the estrogen tablets are considered safe.
Some patients who are more naturally oriented seek other options including over-the-counter lubricants, over-the-counter moisturizers, and herbal/nutrient agents. One natural alternative that has been the subject of a small amount of research is the use of vitamin E suppositories.
A 2014 analysis compared the use of vitamin E 100 IU suppositories with vaginal estrogen cream in 52 menopausal women with symptoms of vulvovaginal atrophy, and a vaginal pH above 5.0.1 Laboratory outcomes included the assessment of the vaginal maturation value (VMV), and Menopause-Specific-Quality of Life (MENQOL) questionnaire. Participants in the study were given 12 weeks of either vitamin E vaginal suppository or conjugated estrogen vaginal cream, 0.625 mg (0.5 gm is equivalent to 1.8 gm of the cream in the applicator). They were instructed to insert the item nightly for the first two weeks and then twice per week for the next 10 weeks.
Results showed that quality of life scores were not significantly different in the two groups after 4, 8 and 12 weeks of treatment. While this sounds positive, that the vitamin E suppository worked basically as well as the vaginal estrogen product, there were no specifics comparing the level of burning, dryness, pain, itching, or urinary incontinence. Rather, the physical symptoms were combined as one of the overall four categories of quality of life assessment:
- vasomotor symptoms (hot flashes/night sweats)
- psychosocial
- physical
- sexual
In this particular study, the physical symptoms did score about 20 points better in the vaginal estrogen group than the vitamin E group. So if the estrogen appears to be better at alleviating physical symptoms, the question becomes one of safety. It is my clinical view that vaginal estrogen is completely safe with the type of regimen used in this study: nightly for two weeks then twice weekly for maintenance. For breast cancer survivors, vaginal estrogen in the form of tablets, a ring or a suppository at this dose and frequency is not associated with a meaningful or lingering elevation in blood levels of estrogen, whereas cream raises blood levels more, and is usually avoided in breast cancer patients. For women with a history of uterine or ovarian cancer, the published research would support the use of vaginal estrogen tablets/suppositories and a local dosing of a vaginal estrogen ring (ex/ESTRING) as safe.2 Even estrogen cream is now considered safe in uterine and ovarian cancer patients.
For my patients who are trying to avoid vaginal estrogen at any dose, other natural products I often prescribe for vulvovaginal atrophy include a fennel cream, a hyaluronic acid/E/A suppository, and a Pueraria mirifica vaginal gel. In addition to the small amount of research on these natural products, there is clinical anecdotal evidence to support their use and they all have excellent safety profiles.
For my patients who are struggling with severe genitourinary atrophy to the point where it is interrupting the quality of their lives, I have no problem prescribing vaginal estrogen in the form of tablets, a ring or a suppository. For my patients with no history of cancer and not at an increased risk of developing estrogen-dependent cancers, I have no problem prescribing the vaginal estrogen cream.
Dr. Tori Hudson directs the curriculum for post-graduate training in women's health at the Institute of Women's Health and Integrative Medicine, and is the director of product research and education for VITANICA. For more information on Dr. Hudson visit http://drtorihudson.com/.
