Unfortunately, I missed the 2023 AUA Advanced Practice Providers meeting in Chicago this year. And I was the speaker!!! I had a fabulous talk on dermatology for the urology advanced practice providers but contracted COVID for the third time! That virus kept me down for over 3 weeks, and I hear that I missed a great conference. I still wanted to present something to my advanced practice colleagues because I feel so passionate about the use of topical estrogen for menopausal symptoms.

Vulvovaginal atrophy has been discussed for years. We’ve all heard about hormone replacement and/or vaginal estrogen for the treatment of genital complaints, but do women really want to insert cream into their vagina nightly? There is a different way. This treatment has few side effects, and it is much less messy than vaginal creams.

Genitourinary syndrome of menopause (GSM) is a fairly new term and replaces vaginal atrophy. It was instituted in 2014 by experts from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. They felt that the term encompassed the genital, sexual, and urinary symptoms related to estrogen decline in ways that previous terms did not. GSM, as defined by Kim et al, “describes various menopausal symptoms and signs including not only genital symptoms (dryness, burning, and irritation), and sexual symptoms (lack of lubrication, discomfort or pain, and impaired function), but also urinary symptoms (urgency, dysuria, and recurrent UTIs).”¹ How many patients present to our clinics with complaints of a UTI, with their main complaint of burning with urination? Some providers will treat these patients for a UTI, based solely on these symptoms, but we all know that a urinalysis, and preferably a urine culture, are preferred methods for diagnosing a UTI. Many of our referral patients have been treated repeatedly for urine cultures that are negative. So, what are we to do? We need to think about our patient and “look down there”! I truly believe it is the only way to ensure that what we are treating is a menopausal problem vs a more alarming dermatological condition. Dermatologic conditions can cause severe dysuria and burning. Common descriptors for menopausal genitalia are thin, pale, erythema, narrowing of the vaginal opening, resorption of the labia, and urethral prominence. While we can infer these symptoms are present in menopausal women, a visual inspection is preferred. Other causes for these symptoms can include herpes simplex infections, lichen sclerosus/planus and/or dermatitis, to name a few. We need to know what we are dealing with.

Pharmaceutical options for GSM include oral hormone replacement, vaginal creams, rings, or suppositories, nonhormonal creams and lubricants, and anesthetic creams. For the best reversal of genital symptoms topical estrogens are preferred. My personal practice is to recommend topical estrogen to all my menopausal patients. Many women have symptoms of GSM, but they do not express those concerns to their health care providers. Therefore, they suffer in silence, with vulvar irritation and painful intercourse being 2 of the largest complaints that providers see in practice. This can be very debilitating for women, leading to depression, decreased quality of life, and issues with their sexual partner, which can affect their relationships. I recently heard a patient say that their doctor told them that pain with intercourse was normal for older women. That is not true! Please do not negate this issue.

I prefer to use topical estrogen, meaning “on the skin” and not in the vagina (although vaginal dosing is totally acceptable) for GSM patients. I recommend using a pea-sized amount, or one-half fingertip length, of cream and rubbing it into the introitus/vestibule area. It can also be applied to the urethra for recurrent UTI patients, as preventive therapy for recurrent UTIs. This route allows for good absorption and is less messy than inserting vaginal creams. I have patients apply the cream nightly for 1 month, followed by 2 to 3 times per week. Epithelial cell turnover takes place approximately every 30 days, which is my rationale for a full month of nightly treatment. Maintenance, or continued therapy, allows the epithelial changes to persist. Most patients will notice an improvement of their symptoms after the first 30 days of use, but it may take longer. It is important to stress that persistence is key, and that continued use is the only way to keep the symptoms from returning. Patients hopefully with notice increased vaginal secretions and less vaginal dryness, less painful intercourse, less burning with urination, and possibly a decrease in UTIs.

For those patients with a history of breast or gynecologic cancer, guidance should be obtained from their oncologist prior to using a hormonal therapy. Low-potency estradiol 0.03% compounded cream is sometimes acceptable in this patient population. This medication is not Food and Drug Administration approved and can only be purchased through compounded pharmacies. Because very little hormone enters the body systemically, risk with topical therapy is potentially less risky. Santen et al found that low- and ultralow-dose hormonal therapy showed negligible levels of estradiol in the blood stream, with the administration of vaginal products. It would make sense that the topical route would also show negligible levels in the blood stream. This research also demonstrated difficulty in defining what is considered the basal estradiol level in untreated postmenopausal women. This information would be helpful in determining what is considered an elevated level in at-risk populations.

Cost is always a concern for patients. A tube of estradiol cream can cost between $30 and $60 with the use of a coupon card. Compounding pharmacies charge approximately $50 and up for their low-dose estradiol. The good news is that these creams can last 4 to 6 months if used as described above. While the up-front costs may seem high, the monthly cost is approximately $10 or less. It is important to always write for the generic equivalent to get the best pricing on estrogen products, as some patients have been quoted prices of $200.

Consider the use of topical estrogen in your postmenopausal patients with genitourinary symptoms of menopause. Urogenital symptoms can be significantly improved with proper treatment, improving the lives of women who suffer with these symptoms. Trust me, they will thank you.