Treatment of Urogenital Atrophy

Estrogen replacement therapy is the hallmark of treatment for urogenital atrophy. Because the underlying factor for atrophic changes is a devascularization process, systemic estrogen replacement may not impact the urogenital tissues. This was best described in the recent HERS trial, where stress incontinence symptoms actually worsened on low-dose systemic estrogen replacement therapy.4

Table 11-1.2. Urogynecologic aspects of local estrogen replacement Primary indications Atrophy with urgency, frequency, nocturia Atrophy with recurrent cystitis Along with pessary use Preparation for reconstructive surgery

Other uses

With alpha-agonist for stress incontinence Postoperative mucosal maintenance Safe usage regimen

Intravaginal cream 1 g 2 nights per week Vaginal tablets 25 |ig 2 nights per week

If necessary, confirm lack of absorption by measuring estradiol level after 6-8 wk of therapy

Local estrogen therapy is the preferred therapy for symptoms and signs of urogenital atrophy (Table 11-1.2). There are various preparations available for this purpose:

1. Vaginal estrogen cream. Various preparations are available to supply estrogen to the urogenital tissues in a cream vehicle - conjugated estrogens (Premarin, Wyeth Pharmaceuticals), estradiol (Estrace, Mead Johnson), and estriol (not available in the United States). There do not seem to be any significant differences in bioavailability or potency between the different products available in the United States. The recommended dosage for local replacement therapy is 0.5 to 1.0g, 2 to 3 nights per week.5 We typically recommend 1.0 g 2 nights per week, placed deep within the vagina with an applicator for women who are symptomatic, being prepared for reconstructive surgery, and postoperatively in women who have undergone pelvic reconstructive therapy.

2. Vaginal estrogen tablets. Twenty-five-microgram estradiol tablets (Vagifem, Novo Nordisk) are available for intravaginal use. These tablets contain estradiol in a cellulose matrix such that as the tablet dissolves, the material coats the vaginal mucosa. It is considered by patients to be less messy, although it seems to not have as prompt an effect on vaginal atrophy symptoms as does cream. When we use Vagifem, we recommend 1 tablet, 2 to 3 nights per week.

3. Estrogen ring. The estradiol ring (Estring, Pfizer) is placed within the vaginal canal and left in place for 3 months at a time. Its popularity has been somewhat less than the other two formulations, but it is useful in providing local estrogen therapy. It is small and therefore does not function as a pessary. Vaginal rings are also available for systemic estrogen replacement therapy.

4. Other formulations. In Europe, Latin America, and other places around the world, vaginal suppositories and pessaries are available for local estrogen therapy. We do not have any experience with that form of therapy in the United States.

It must be emphasized to patients that low-dose local vaginal estrogen therapy, in the doses noted above, does not result in significant absorption into the systemic circulation.5 As such, patients should not be concerned about systemic effects of local estrogen therapy. In patients who are concerned, we will obtain a serum estradiol level before initiating therapy, as well as 6 weeks after the patient has begun therapy, to demonstrate the lack of significant systemic absorption. This may be particularly important for young women who have undergone chemotherapy for breast cancer, and are severely atrophic.

In some women, the use of concomitant systemic and local estrogen replacement therapy will result in a revas-cularization of the vaginal mucosa and the possibility of discontinuation of local estrogen therapy once increased vaginal blood flow is documented.

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