Does a woman with an intact uterus and ovaries being treated with topical vaginal estrogen need to be covered with oral progesterone as well? — Michelle Owens, FNP, New Ulm, Minn.

Vaginal estrogen is used to treat vaginal atrophy in peri- and postmenopausal women. The most common complaints that indicate vaginal atrophy are vaginal dryness, itching, irritation, burning, and dysparunia. Treatment options include creams, pills and rings.

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At low-dose regimens, these estrogens have not been shown to cause endometrial hyperplasia, so an opposing progesterone is not required, provided that the following doses are not exceeded:

  1. Estradiol tablet (Vagifem) 10 µg (one tablet per vagina every night at bedtime for 14 days, then one tablet per vagina twice a week)
  2. Estradiol ring (Estring) 7.5 µg (place one ring per vagina for 90 days, repeat)
  3. Estradiol cream (Estrace, Ogen, Premarin) 1 g cream (100 mg estradiol) (1 g cream per vagina every night at bedtime for two weeks, then 0.5 g twice a week thereafter).

If a woman still has her uterus and requires more estrogen than the low-dose regimens, she will need progesterone as well to protect from endometrial hyperplasia and cancer. I recommend micronized progesterone (Prometrium)100 mg every night at bedtime.

Another option is to cycle in micronized progesterone 200 mg for 12 days of every month, after which she may experience a withdrawal bleed. I advise against medroxyprogesterone (Provera), as this synthetic progesterone may increase risk of breast cancer as well as blood clot. Be aware that a woman with a history of breast cancer should not be given estrogen at any dosage without consultation with her oncologist. — Mary Newberry, CNM, MSN (182-3)

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