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.
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:
- Estradiol tablet (Vagifem) 10 µg (one tablet per vagina every night at bedtime for 14 days, then one tablet per vagina twice a week)
- Estradiol ring (Estring) 7.5 µg (place one ring per vagina for 90 days, repeat)
- 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)
These are letters from practitioners around the country who want to share their clinical problems and successes, observations and pearls with their colleagues. We invite you to participate. If you have a question, submit it here.