Kim (00:04.556)
All right. So it's just me today and I'm going to be reading from an article that I wrote, evidence informed article about vaginal estrogen. I'm recording this episode actually from Austin, Texas. And I'm quite a big fan of Austin. I think I will come back here. My son is playing in a soccer tournament in Dallas and my husband and I decided we would take an opportunity.
to explore a little bit more of Texas before we went to see him in Dallas play with his team. My former business partner, Julia DiPaolo, soon to be Dr. Julia DiPaolo, she moved to Texas about a year and a half ago, and I have always wanted an excuse to come and see her, and this was a great opportunity. So we started our trip in Houston, had a few days with her in the, just outside of the Houston area. Then we,
We drove to a place called Rockport on the beach. Then we drove the scenic route up to Austin. And so far this has been the best part of the trip. Not that hanging with Julia wasn't fun, that was awesome. But in terms of the city and where we are, we're digging Austin. Okay, so I'm gonna go through this article. I will be reading through the article.
I will post a link in the show notes to the article that has all of the links to the studies that I reference and feel free to share, feel free to bring it into a care provider perhaps. In the show notes, I am also going to list all of the resources that I use to get my information, to do my research, the people that I trust, the resources that I trust.
so that you can take this and also information from others and other resources and then make your informed choice to make the decision that's best for you and your body. So this is all about vaginal estrogen and other helpful therapies for vaginal dryness. Anybody who has followed for a while, you know that I am not a doctor. I am not a hormone specialist. I am nearing the completion of my menopause support practitioner certification.
Kim (02:24.621)
And I myself am also post menopause and have been heavily into research for my own body over the last, I'd say probably like eight, eight -ish years. I follow the evidence and look to both vocal advocates for female sexual health and wellness like Dr. Kelly Casperson and Dr. Rachel Rubin. And this is a summary of some.
but not all of the research as it pertains to vaginal health post menopause, namely genitourinary syndrome of menopause and how it can be treated with estrogen and other products. So you can take this information and consult your healthcare provider to determine which is the best option for you and your vagina.
Kim (03:13.997)
Short story, vaginas love estrogen. Estrogen is our juicy, supple hormone, and as we approach and move beyond menopause, our estrogen production comes to a halt, leaving our vaginas and the tissues around the labia, the clitoris, the urethra, and the bladder in a less than supple state, shall we say. Vaginal dryness affects over 80 % of women, and it is not something that improves with time.
Vaginal dryness is also a common occurrence postpartum, also with the use of birth control pills and other medications, as well as various cancer treatments. Vaginal estrogen and vaginal moisturizers can help overcome this and may even prevent it from happening in the first place. But unfortunately, many women are either not aware of what GSM is, they don't know how to treat it, maybe they're afraid of estrogen,
or maybe they are denied access by their care provider. So hopefully this article will help set the record straight. So how do the vagina and the vulva change with age and when estrogen decreases? The vagina, the lower urinary tract, including the bladder and the urethra, and the pelvic floor all contain estrogen receptors. When estrogen declines, the tissues become thinner and drier and they can atrophy or shrink.
This can contribute to a host of symptoms that fall under the term genitourinary syndrome of menopause, GSM. Recently, a new sister term has been proposed, GSL, or genitourinary syndrome of lactation, which identifies another similar low estrogen state in the postpartum period. As we age and move beyond menopause, we also experience
age -related muscle loss, especially of the type two muscle fibers, which are the ones associated with speed and power. We experience collagen loss. You can also see my collagen episode and article. And also, we experience hyaluronic acid loss. So all of these can contribute as well to the signs and symptoms of GSM.
Kim (05:31.756)
We're going to talk about the common symptoms associated with low estrogen and GSM. So as we mentioned, it's a collection of signs and symptoms that affect the labia majora, the labia minora, the clitoris, the vestibule or the entroitis, the vagina, the urethra and the bladder. Genital symptoms could include dryness, burning, itching, irritation. Sexual symptoms may include lack of lubrication,
pain, bleeding during or after intercourse, burning, impaired function. And urinary symptoms may include urgency, frequency, nocturia, which is waking frequently at night to pee, and recurrent UTIs or urinary tract infections. As I mentioned, GSM is very common and upwards of 80 % of women postmenopause experience these symptoms.
And women may present with some or all of the signs and symptoms and most don't know they can be as a result of low estrogen either because they have never been taught or told, they've never been asked about any symptoms, and because they are many years post menopause and they think that it doesn't apply to them anymore.
Unlike other symptoms associated with the menopause transition, vaginal dryness and the other signs and symptoms do not get better with time and many women have progressive symptoms that become most bothersome five to 10 years after the onset of menopause, which in North America has an average age of 51. How is GSM treated? There are several options available to women suffering with symptoms associated with GSM, including moisturizers, lasers,
lubricants for sexual activity, ospemophene, testosterone, vaginal DHEA, c -buckthorn oil, and vaginal estrogen, with vaginal estrogen being considered the gold standard.
Kim (07:38.795)
We'll talk here about vaginal estrogen. These are estrogens delivered locally to the vagina by tablets, pessaries, and creams. They are the most common and highly recommended platforms to treat the GSM. Dryness, burning, irritation, painful sex, also called dyspareunia, frequent UTIs, urinary frequency, and urgency.
are the most common symptoms of GSM and estrogen products have been found to be clinically effective for the treatment of GSM with doses as low as four micrograms. One study showed that topical estrogen therapy ameliorates overactive bladder in female patients. Another study showed that all commercially available vaginal estrogens effectively relieve common vulval vaginal atrophy related complaints,
and have additional utility in patients with urinary urgency, frequency or nocturia, stress urinary incontinence, and urge urinary incontinence and recurrent UTIs. The cost of UTIs is calculated at $1 ,222 per UTI.
And the reduction in UTI spending can range between $3 ,670 and $5 ,499 per beneficiary per year. Topical estrogens are a cost -conscious way to improve the burden of UTI on postmenopausal women with the potential for billions of dollars in Medicare savings. The other important factor to consider is the risks of chronic UTIs to kidney function and also
the potential of sepsis. Reducing the risk of UTIs is one of the major reasons, in my opinion, for vaginal estrogen as a preventive and restorative therapy. Multiple randomized clinical trials have successfully been completed to show the efficacy of local estrogen preparations for the treatment of UTIs. Prevention of painful sex dyspyridia is another reason for using vaginal estrogen.
Kim (09:54.282)
So many women are missing out on pleasure and intimacy because of pain associated with vulvovaginal atrophy. Very low dose estradiol vaginal cream dosed twice weekly is an effective and well tolerated treatment for vulvovaginal atrophy symptoms and dryness associated with menopause. The Rejoice trial was a randomized
control trial evaluating the safety and efficacy of a novel vaginal estradiol soft gel capsule for symptomatic vulvovaginal atrophy and found that 4, 10, and 25 micrograms was safe, well tolerated, and effective for treating moderate to severe dyspareunia within two weeks with minimal systemic estrogen exposure. When looking at moisturizers and estrogen compared, this study
the one that I will link below, demonstrated that treatment with low dose vaginal estradiol but not vaginal moisturizer modestly improved menopause -related quality of life and sexual function domain scores in postmenopausal women with moderate to severe vulvovaginal symptoms. Another study highlighted that the recently FDA approved estradiol soft gel vaginal insert at four micrograms and 10 micrograms,
was safe and effective over 12 weeks for treating moderate to severe dysparenia due to menopausal vulvophaginal atrophy with minimal systemic estradiol levels. Estrogen helps maintain the pH of the vagina. When estrogen is low, the vagina becomes less acidic and more prone to infection. Further, lactobacilli is a group of bacteria shown to produce antimicrobial and anti -inflammatory factors.
and that also metabolize glycogen -derived polymers into lactic acid. The production of lactic acid in turn lowers the pH of the vagina and helps maintain its optimal acidic state. Women receiving vaginal estradiol experienced a greater abundance of lactobacilli and lower vaginal pH at the end of treatment. Another study demonstrated that vaginal estradiol tablets resulted in substantial changes
Kim (12:16.552)
in the vaginal microbiota and metabolome with a lowering in pH, particularly in women with high diversity bacterial communities at baseline. Low pH moisturizer or placebo did not significantly impact the vaginal microbiota or the metabolome despite lowering the vaginal pH. Estradiol use may offer additional genitourinary health benefits to postmenopausal women.
Now we'll look at vaginal moisturizers. It is well established that vaginal moisturizers containing hyaluronic acid are effective in alleviating vaginal dryness from any cause. Hyaluronic acid is a naturally occurring molecule in the body and has the capacity to retain huge amounts of moisture. We produce less hyaluronic acid as we age, and this plays a role in less hydration and plumpness in our tissues.
One study found that hyaluronic acid vaginal gel was not inferior to estriol vaginal cream in women presenting with vaginal dryness. And another study found that hyaluronic acid and estrogen in the form of estradiol were equally effective in vulvovaginal atrophy treatment. A systematic review of five primary studies involving 335 women published between the years of
2011 and 2017, suggests that treatment with hyaluronic acid when compared with the use of estrogens does not present a significant difference in the results obtained for the outcomes of epithelial atrophy, vaginal pH, dyspareunia, and cell maturation.
A randomized control trial compared the LadyLift vaginal laser with hyaluronic acid suppositories and found no difference between the two regimens. Just over 20 women in each group, both had intravaginal, sorry, both intravaginal laser therapy and hyaluronic acid suppositories are effective treatment options for women after breast cancer suffering from urogenital atrophy.
Kim (14:30.345)
To add on here, a systematic review and meta -analysis looked at the severity of GSM symptoms after carbon dioxide laser versus vaginal estrogen therapy and found that vaginal laser treatment is associated with similar improvement in genitourinary symptoms, just as vaginal estrogen therapy is. I love that we have new therapies and technologies coming out all the time, and I think there is a huge potential for lasers and radio frequency and energy techniques.
but they are costly and they are not accessible to everyone. Astrogen and moisturizers are much more affordable and accessible to most. I recommend women moisturizer vagina daily with a hyaluronic acid based vaginal moisturizer. Moving on to sea buckthorn oil. Sea buckthorn and its bioactive ingredients may have potential in the management of gynecological problems such as uterine inflammation,
endometriosis and easing symptoms of vulvovaginal atrophy in postmenopausal women by targeting inflammatory cytokines and vascular endothelial growth factors. In a double -blind placebo -controlled trial looking at the effects of oral c -buckthorn oil intake on vaginal atrophy in postmenopausal women, it was found that compared to placebo, there was a significantly better rate of improvement in the integrity of the vaginal epithelium
in the cbuckthorn group.
Another double -blind randomized placebo -controlled study looked at the efficacy and safety of a new vaginal gel for the treatment of symptoms associated with vulvulvaginal atrophy in postmenopausal women and found that the vaginal gel was effective in reducing vaginal pain, dysparenia, and vaginal pH, and that the vaginal health index showed significant improvement at day 90. It was also effective in reducing vaginal dryness, vaginal itching, and burning sensations at weeks.
Kim (16:28.84)
two and four and at the end of the study. The analysis also showed after the end of treatment, an improvement in sexual function in the active treatment group. The gel contained sea buckthorn oil, aloe vera, 18 beta glycerinatinic acid, I know I'm not saying that correctly, which is one of the main constituents in licorice, hyaluronic acid and glycogen. So I think that's a really promising.
treatment. And again, it's taken orally not put into the vagina. Now moving on to aspermophene.
A trademark name, osphina, was approved by the US Food and Drug Administration in 2013 after 20 plus years in development. It has been approved for the treatment of moderate to severe dyspyrunia, again that's painful sex associated with vulvaginal atrophy, now called GSM, due to menopause.
Aspimophene is an oral nonsteroidal estrogen receptor agonist antagonist, also known as a selective estrogen receptor modulator or a CIRM. It is from the same chemical class as the breast cancer drugs tamoxifen and toremophene, but unlike other selective estrogen receptor modulators, aspimophene exerts a strong almost full estrogen agonist effect on the vaginal epithelial.
making it well suited for the treatment of painful sex in post menopausal women. This is an important point in that it is indicated for the treatment of painful sex, not the urinary symptoms or the UTI prevention and treatment. Moving on to vaginal DHEA. Here's another big word. DHEA stands for dihydroepiandrosterone, also known as prasterone. And it's an ad.
Kim (18:25.872)
androgen like testosterone, and androgens contribute to the maintenance of genitourinary tissue structure and function. Similar to estrogen, DHEA plays a role in the integrity of skin, muscle, and bone and plays a role in libido. DHEA is produced in the adrenal glands and is a precursor to the production of estrogen and testosterone.
As we approach and move beyond menopause, our ovaries stop producing estrogen and we begin to source our hormones from our adrenals. DHEA is a major source of our estrogen production, but like our other hormones, our production slows as we approach and move beyond menopause. If DHEA is delivered directly to the vagina, the tissues convert the DHEA to estrogen in the form of estradiol.
In one study, daily intravaginal administration of DHEA caused highly statistically significant improvements in four measurements of vaginal atrophy. At gynecological evaluation, vaginal secretions, epithelial integrity, epithelial surface thickness, and color all improved by 86 to 120 % over the placebo effect, and vaginal pH decreased by 0 .66 pH units over placebo.
Daily, 6 .5 milligrams of Prasterone appears to be at least as efficacious as 0 .3 milligrams of conjugated equine estrogen or 10 micrograms of estradiol for treatment of vulvovaginal atrophy symptoms. Intrarosa is an FDA and Health Canada approved vaginal DHEA. An over -the -counter option is Jalva made by my friend and colleague, Dr. Anna Kabeca, and this is a personal favorite of mine.
I use vaginal estrogen in the form of Vagifem, which is a tablet, and a compounded Estriol cream twice a week. I then use Jalva on alternate nights. Dosing of vaginal estrogen will be determined by your doctor. So this is my personal dosing, and again, yours will be determined based on your care provider. Now we're gonna look at testosterone. We...
Kim (20:43.816)
don't often think of testosterone being helpful for women. In a double blind randomized placebo controlled trial, they wanted to investigate the effects of intravaginal testosterone on sexual satisfaction, vaginal symptoms, and urinary incontinence associated with aromatase inhibitor use. Intravaginal testosterone cream, 300 micrograms per dose, was what was used.
and there was an identical placebo, and it was self -administered daily for two weeks and then three times weekly for 24 weeks. Intervaginal testosterone significantly improved sexual satisfaction and reduced dyspareunia in postmenopausal women on aromatase inhibitor therapy. Another study wanted to evaluate the safety of intervaginal testosterone cream or an estradiol -releasing vaginal ring, such as the S -string or the E -string.
in patients with early stage breast cancer receiving an aromatase inhibitor. Postmenopausal women with hormone receptor, HR positive, stage one to stage three breast cancer, taking aromatase inhibitors with self -reported vaginal dryness, dyspheronia, or decreased libido were randomized to 12 weeks of the intravaginal testosterone or an estradiol vaginal ring.
vaginal atrophy, sexual interest, and sexual dysfunction were improved. To note, a cross -sectional study found that low serum testosterone is associated with an increased likelihood of overactive bladder in women. This supports the potential therapeutic role of testosterone supplementation in women with overactive bladder. Given the direct and indirect effects of testosterone on the pelvic floor and lower urinary tract,
A potential mechanism for this relationship can be further explored in other studies. Another study found that low serum testosterone is associated with an increased likelihood of stress and mixed urinary incontinence in women. And a recent review found that the levator anii, which is one part of the pelvic floor, and other muscles of the pelvic floor and lower urinary tract are sensitive to the anabolic effects of testosterone.
Kim (23:06.214)
Androgen receptors are also expressed in the pelvic floor and urinary tract, lower urinary tract of both animals and humans. Anabolic effects of androgens may play an important role in the female pelvic floor and lower urinary tract disorders. Further, the interactions between androgen and nitric oxide synthase and argonase have been demonstrated, suggesting that androgens may also participate in modulating the physiological functions,
of the lower urinary tract through nitric oxide. I'm excited that testosterone therapy is being more researched and talked about as it pertains to women. And it's my hope that it will become more accessible for women for pelvic health and overall health benefits. Currently in many parts of the world, it is very difficult, sometimes impossible to obtain testosterone therapy. And I'm hopeful that more and more research will open up the gates for that.
So I can't write an article without mentioning a pelvic floor muscle training. Pelvic floor muscle training is well established as an effective intervention for improving health -related, quality -of -life -related urinary symptoms in postmenopausal women. However, there remains insufficient evidence to assess the effectiveness of Kegel exercises on health -related, quality -of -life -related genital symptoms in this population.
The results support using Kegels as a useful intervention to manage urinary symptoms in postmenopausal women. Optimizing pelvic floor muscle function will also ensure proper blood flow and circulation, which can aid and help with lubrication and insertive sex and sexual pleasure. So what is the best mode of delivery of vaginal estrogen? I've hinted at a few things here.
Based on a Cochrane review, all forms of vaginal estrogen are similarly effective. It's personal preference as to which is best for you and you would work that out with your care provider. Before we explore the different options, it's important to understand the term bioidentical. This is often said by some to be just a marketing claim. However, it is important to know when it comes to hormone therapy.
Kim (25:25.115)
Bioidentical, sometimes referred to as body identical, means that the estrogen is the same chemical structure as our own body makes. Non -bioidentical is not the same chemical structure as our body makes. Conjugated equine estrogen is a pharmaceutical with hormone -like effects sourced from pregnant horse's urine, commonly known as Premarin, and it is not bioidentical. All prescription vaginal estrogen therapy is synthetic.
meaning it's manufactured in a lab, regardless of if it is bioidentical or not. So we can't say bioidentical versus synthetic because even bioidentical is synthetic. It's bioidentical or not bioidentical. It's also important to understand the different types of estrogen. So estrone, we have three types. Estrone is when the ovaries are no longer producing eggs.
which is our menopause, postmenopause. Estrone is the dominant form of estrogen produced primarily in fat tissue by converting DHEA. And it does much of the same thing as estradiol, but is considered weaker and more inflammatory. Estradiol is produced by the developing eggs in the ovaries during the reproductive years. Estriol is the weakest form of estrogen and it's produced primarily in pregnancy.
The majority of estrogen therapies are estradiol or estriol. There are some that are estrone, but the majority are estradiol or estriol. Some of the common brand names, this is North America focused based on where I live, but also the vast majority of who I support in my community.
So this is not an exhaustive global list. At some point, I would love to update this article with formulations all around the world, but for right now, this is North America. Vagifem is an FDA and Health Canada approved tablet form of bioidentical estradiol that is inserted into the vagina with a preloaded applicator. Estrace is a bioidentical estradiol
Kim (27:52.329)
currently available in the United States. Estrogine is an Estrone cream currently available in Canada and I believe in the US as well. But again, it is, it's not my preferred source. It can convert to estradiol, but I feel it's more beneficial to just go with the estradiol right from the get -go.
The S string or the E string is a small pessary that is inserted into the vagina with estradiol and is left in for a period of time and then is replaced with a new one. So the benefit is you don't need to think about it. You put it in and then you get your reminder and you take it out and replace it. Some people who may have more advanced prolapse may find that it doesn't stay in place or they may find that it is uncomfortable. Invexy is a vaginal estradiol insert.
bioidentical. And so there's lots of different forms. And again, you can work with your care provider to determine which is the best option for you, which is the most, the most cost effective for you as well. I would say there's a benefit to the cream because it can be inserted and used externally. So when we were talking about GSM, it can affect the internal and external tissues, the labia, the clitoris. So,
being able to apply the cream all over is beneficial, especially if you have thinning tissues that are like if your labia are starting to retract or thin and especially at the actual introitus, the opening of the vagina is one of the areas that is most commonly associated with vaginal dryness and painful interchoristis perunia. So,
That would be a preference for many, but some people don't like the mess of a cream, they prefer a tablet. Some people may use a tablet and an Estriol, which is a little bit weaker form of estrogen and very helpful for inflammation. They maybe use that external externally and the tablet internally. So there's all sorts of different ways that you can use it. And again, working with a qualified care provider to find the best option for you is recommended. There's also,
Kim (30:17.847)
compounding. Compounding is where you would take your prescription to a compounding pharmacist who would then put the estradiol or the estriol into a different base that may not have certain ingredients in it. Some of the preparations that come from Health Canada and the FDA may have things like parabens and those are
not great, so many people do not want anything with parabens. They may also be sensitive to some of the other ingredients. So by having it compounded, it may allow them to use a base that they would have less or no sensitivity to. It is more costly, but it is an option. So in terms of how long and how often, the typical dose is twice a week. However, you will work with your care provider to determine the best delivery mode and the best dose for you.
Some may start with a loading dose of once daily for two weeks and then twice a week thereafter. But sometimes people find the loading dose too strong and they do experience some irritation. And the irritation can be from too much too soon, or it may be irritation from some of the filler ingredients, as I mentioned. Getting your vaginal estrogen compounded could help reduce that. So again, it's sometimes a little bit of trial and error. For those that have been in a low estrogen state for a while, when...
you first start taking vaginal estrogen, you may experience a yeast overgrowth or an infection as the vaginal microbiome starts to adjust to the benefits of the estrogen. That's not uncommon. So again, playing around with the dose, but most people find that not doing the loading dose is the least likely for them to have any sort of reaction. With regards to how long you will use vaginal estrogen, the answer is basically until you die.
As they shared earlier, the signs and symptoms of GSM do not improve with time. So if you stop using your vaginal estrogen, the signs and symptoms will return. What about the risks? People are afraid of estrogen. The Women's Health Initiative scared the pants off everybody. And now everybody thinks that estrogen is going to give you heart disease and cancer. And unfortunately, the pamphlets,
Kim (32:33.642)
that are inside your vaginal estrogen will tell you that it's very dangerous and harmful and you're going to die. And that stops a lot of people. They get their prescription, they bring it home and they read it and they say, oh my God, this is too risky for me, I'm not going to do it. Dr. Rachel Rubin and Dr. Kelly Casperson, I believe with maybe a few other people are working, they're petitioning the FDA to make changes to those inserts because they are not evidence -based.
There is no evidence about what is claimed. Anything estrogen has the exact same claims on it. And a lot of this is the hangover from the Women's Health Initiative. So contrary to what the pamphlets tell you, vaginal estrogen is not dangerous or harmful. It is incredibly low dose and little to no estrogen makes it into the bloodstream. One year's worth of typical vaginal estrogen dosing is the equivalent to one oral estrogen pill.
and many people are put on the pill with no question, no problem, and people take it without any question. People also drink alcohol without question, and those are much greater risks for adverse effects compared to vaginal estrogen, which has no links to any cancers of any kinds or any cardiovascular disease. So vaginal estrogen is remarkably safe, even for individuals with a history of breast cancer or cardiovascular disease.
And one study showed no evidence of increased early breast cancer specific mortality in patients who used vaginal estrogen compared with patients who did not use hormone replacement therapy. Another study is not referencing vaginal estrogen per se, but rather systemic estrogen. And it's interesting to note that there were lower risks of recurrence and mortality of breast cancer in women who used HRT after breast cancer diagnosis than in women who did not.
Another study showed that hormone replacement therapy use in women with a family history of breast cancer is not associated with a significantly increased incidence of breast cancer, but is associated with significantly reduced total mortality rate. Now again, this is systemic, not vaginal. So I've kind of veered off there a little, but I think it's important to note because the doses of estrogen with systemic is much greater than what is used vaginally.
Kim (34:56.426)
The real world nationwide Danish population study found that increasing duration and intensity of use of vaginal estradiol tablets was not found to be associated with an increased risk of breast cancer.
Healthy aging and longevity are keen interests of mine right now, and I want to age gracefully and powerfully, and I am not interested in suffering. Bioidentical vaginal estrogen and systemic hormone therapy are choices that I have made based on all the evidence to their benefits and little to no risks. As I mentioned earlier, I will share links in the show notes to my favorite evidence -informed resources about menopause and hormones.
vaginal hormone therapy as well as systemic. So that is it for this episode. Again, this is a summary. This is definitely not an exhaustive list of all of the different research and evidence or even all of the different ways that we can help. So these are the primary evidence -based practices and therapies that we have.
and loads and loads of more research I know will come. And I will keep this episode up to date as more and more research is shared. I will also update this article so that as it floats around the internet, it will always have the most up -to -date research as well. Thanks again. We'll see you in next week's episode.
