Is there a recommended duration of topical estradiol therapy for postmenopausal women with symptoms of vulvovaginal atrophy? Would progesterone help counteract endometrial hyperplasia? If so, is there a recommended dosage and frequency?—MORGAN STRYKER, PA-C, Santa Cruz, Calif.

Risk and benefits of estrogen therapy must be individualized. While estrogens are very effective in alleviating postmenopausal symptoms (including atrophy of the vagina), they are associated with increased risk of breast and uterine cancer, cardiovascular disease, and dementia. If atrophic vaginitis is the patient’s primary complaint, topical rather than systemic estrogen is preferred. Topical estrogen is available in cream, tablet, or ring formulations. Adding progesterone has been shown to decrease the risk of cancers but may result in breakthrough bleeding. Any abnormal bleeding in a postmenopausal woman, whether on progesterone or not, should prompt endometrial biopsy. Dosage of progesterone has not been standardized, but the recommendation is to use the lowest dose possible.—Claire Babcock O’Connell, MPH, PA-C (131-6)