Vaginal Estrogen (VE) therapy is a localized treatment for Genitourinary Syndrome of Menopause (GSM). This condition, previously known as vulvovaginal atrophy, involves changes to the vulva, vagina, and lower urinary tract tissue due to reduced estrogen levels. VE works directly on these tissues to restore their health, increase lubrication, and normalize the vaginal pH. Because it is applied directly to the affected area, the treatment is effective at a much lower dose and results in minimal absorption of estrogen into the bloodstream compared to oral hormone therapies.
Delivery Methods for Vaginal Estrogen
Localized vaginal estrogen is available in several forms, allowing treatment to be tailored to patient preferences and needs. The two most common options requiring regular application are creams and tablets, which are the focus of daily or weekly use.
Vaginal creams are estrogen suspended in an emollient base, dispensed using a reusable applicator that allows for precise measurement of the prescribed dose. Vaginal tablets or suppositories are small, solid inserts that dissolve once placed inside the vagina and usually come pre-loaded in a disposable applicator for hygienic insertion. The third method is a vaginal ring, a flexible, soft ring inserted into the upper vagina that continuously releases a low, consistent dose of estrogen over three months before replacement. While all three forms are equally effective for treating GSM, the choice often depends on ease of use and personal preference regarding physical application and frequency.
Step-by-Step Application for Creams and Tablets
Applying Vaginal Cream
Applying vaginal estrogen cream begins with washing your hands thoroughly with soap and water to maintain hygiene. The cream comes with a reusable applicator that must be filled to the prescribed mark (typically 0.5 to 2 grams) by screwing the open end onto the tube and gently squeezing the cream inside. Once filled, unscrew the applicator and securely replace the cap on the cream tube.
To insert the cream, find a comfortable position, such as lying on your back with knees bent or standing with one foot elevated on a chair or toilet seat. Gently insert the applicator deep into the vagina as far as is comfortable. Slowly press the plunger completely to expel the measured dose of cream into the vaginal canal. After delivery, carefully remove the applicator and wash it immediately using warm, soapy water, rinsing well and allowing it to air dry for the next use. Some individuals may measure the dose, squeeze the cream onto a clean finger, and apply it directly inside the vagina and on the external vulvar area instead of using the applicator.
Applying Vaginal Tablets
The application process for vaginal tablets or inserts is similar but typically involves a disposable applicator that is pre-loaded or loaded just before use. Start by washing your hands and unwrapping the applicator, ensuring the tablet remains secured in the tip. Choose a comfortable position, such as lying down or standing with a foot up, and gently insert the applicator into the vagina about halfway or as far as is comfortable.
Once positioned, press the plunger on the applicator to release the tablet, which is often accompanied by a light click, and the tablet will adhere to the vaginal wall. Gently withdraw the applicator and immediately dispose of it, as it is designed for single use to ensure sanitary application. Tablets are often preferred by some users because they tend to result in less noticeable leakage or discharge compared to the cream formulations.
Treatment Schedules and Dosage Guidelines
Vaginal estrogen therapy typically follows a two-phase schedule to first restore the health of the vaginal tissues before maintaining the benefit. The first stage is known as the loading phase, which often involves daily application for a short period, generally lasting one to two weeks. During this phase, the daily dose of cream is usually 0.5 to 1 gram, or a tablet strength of 10 micrograms is used every day.
This initial daily use is designed to quickly saturate the atrophied tissues with estrogen, which helps to rapidly thicken the vaginal lining and improve blood flow. Once tissues have matured and symptoms have significantly improved, the prescribed schedule transitions to the maintenance phase. Maintenance dosing is typically a reduced frequency, most commonly involving application only twice a week, such as every Monday and Thursday. Some patients may require a slightly higher frequency of three times per week, but the goal is always to use the lowest effective dose to control symptoms over the long term.
Safety and Management While Using Vaginal Estrogen
Patients using vaginal estrogen should anticipate minor issues, such as a white or clear discharge or slight leakage, which is common, particularly with the cream formulations. Applying the medication at bedtime is often recommended to maximize absorption and reduce the impact of leakage during the day. Using a panty liner can help manage discharge and prevent staining of clothing.
If a dose is missed, apply it as soon as the oversight is noticed, unless it is already close to the time for the next scheduled dose. In that case, the missed dose should be skipped entirely, and the regular schedule should be resumed with the next dose, as doubling up is not recommended. Contact a healthcare provider immediately if unexpected or abnormal vaginal bleeding occurs after the first few months of treatment. While mild spotting can occur during the first three to six months as the tissues heal, persistent or heavy bleeding requires medical evaluation to rule out other issues. Vaginal estrogen products should be stored at room temperature, away from excessive heat, moisture, and direct light, and kept out of the reach of children and pets.