In 2002, the Women’s Health Initiative contributed a study to The Journal of the American Medical Association on the “Risks and Benefits of Estrogen Plus Progestin in Healthy Post Menopausal Women.” Ten years later, there continues to be fall out from the original findings.
What the average woman may not know is that the hormone replacement therapy studies of 2002 were based on trials with the medications Premarin (estrogen alone) and Prempro (estrogen and progestin), derived from the urine of pregnant mares.
In writing a story about vaginal atrophy and dryness in menopausal women, I spoke to a range of experts with widely different opinions. I learned that there is nothing simple about this conversation. Side bar issues would repeatedly pop up. They included the agenda of pharmaceutical companies, women determining medical choices by insurance and financial considerations, even animal rights issues concerning the production of Premarin.
The goal of this two-part piece is to present material from diverse sources that will inform women so that they can be proactive on behalf of their own well-being.
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Dr. Cheryl Perlis is a board certified gynecologist based in Illinois. After twenty-two years of practicing, she changed her approach by cutting down on the number of patients she saw daily so that she had sufficient time to converse with each person in detail. She has become a “huge advocate” of bioidentical hormone therapy (BHRT). “Women are living longer,” she told me. “Everyone should be on them. It’s the standard of care in Europe.”
Perlis uses estrogen, progesterone, and testosterone to relieve vaginal dryness because “the condition is symptomatic of decreased hormone levels.” Perlis believes, “Nothing works for the vagina, vaginal walls and tissues like estrogen.”
She said, “You can try “holistic remedies, but that they will not get of the core of the problem—which is the lack of hormones, particularly estrogen.” Perlis’s bottom line was, “You can't get a better vagina without hormones.”
Perlis works with compounding pharmacies to create hormone medications tailored to the need of each person. She noted that these prescriptions are not FDA approved, but that they are legal and regulated. She suggested that conservative doctors would be less likely to use them, as they prefer to treat symptoms along “standard guidelines.” When I asked Perlis why these compounds couldn’t get FDA approval, she said, “Because no company is going to go after it in the United States. They are up against Big Pharma.”
Dr. Alyssa Dweck, board certified in Obstetrics and Gynecology and author of V is for Vagina, made clear that choices are “very individual.” First, she said, “you have to have the conversation — as it is not a one size fits all scenario.” She takes the time to thoroughly describe how bioidenticals are “molecularly identical to the hormones that women make in their bodies,” and are synthesized from plant elements such as yams and soy, making them different from a medication like Premarin. Dweck’s approach is to treat with the “lowest dose possible for the shortest amount of time.”
She mentioned three specific products: the Femring, the Estring, and the vaginal tablet Vagifem — stating that the last two were very low in estradiol. The Estring is a flexible vaginal ring that is worn up inside the vagina for three months at a time. Vagifem is a small vaginal estrogen tablet that is inserted twice weekly into the vagina, after an initial “loading dose.” According to Dweck, they “both claim minimal absorption into the bloodstream,” yielding less risk. Bleeding is always a red flag, and Dweck advises a yearly transvaginal ultrasound to make sure that there is no thickening of the uterine lining.
Dweck concurred with Perlis that most Ob-Gyns tend to stay on the traditional path, set forth by the American College of Obstetricians and Gynecologists. Yet she insisted that was not an excuse for doctors to dismiss the concerns of vaginal atrophy or to short circuit describing all potential options. Dweck related, “There are plenty of women who don’t have any symptoms of vulvar or vaginal atrophy. However, for those who do, they don’t necessarily want aggressive treatment. What they do want is reassurance that they are normal.”
She regularly fields questions about vaginal itching, burning, or repeated urinary tract infections. Dweck insists, “Any complaint should be taken seriously.” Then she asks her patients, “Are these problems severe enough that you want treatment?”
Dweck offers information about compounded lubricants to order (including one that contains Hyaluronic acid, Vitamin E, and aloe) or an over-the-counter product such as Replens. She mentioned that orgasms can help with secretions and maintaining vaginal tone. For Dweck, “It all comes down to risks and benefits.” She added, “We have to remove the taboo and embarrassment to make sure that women can have a candid dialogue with their doctors.”
Dr. Deborah Coady, co-author of Healing Painful Sex, evolved into caring specifically for women suffering from sexual and pelvic pain. She pointed to studies that estimate “50 to 75 percent of menopausal women undergo distress from vaginal changes,” yet half of that group revealed that they “learned to live with it.” Only 10 to 20 percent reported “their physicians ever asked them about the problem.” Coady contended, “Women have different phases of life. A doctor still heavily focused on obstetrics may not be the best solution for an older woman’s concerns.”
Coady was the only physician to speak to me about the “vaginal vestibule,” which is the opening of the vagina. Particularly vulnerable in menopausal women, it becomes delicate and raw when estrogen levels go down. Any plan for vaginal health should apply to both sexually active and non-sexually active women. She reiterated the maxim that using the lowest amounts of estrogen is always the optimum approach. Coady supports using a prescription topically and locally to treat the vestibule that won’t impact the bloodstream. She uses a custom compounded cream in a preservative-free base without parabens and propylene glycol (she referenced the Women’s International Pharmacy as her source).
Coady clarified that since vestibular tissue is “especially rich in hormone receptors,” when they lack the “optimal amounts of hormones, they atrophy or thin.” For intravaginal use, she recommends gel caps of Estriol and DHEA nightly for two weeks, before moving into a maintenance program of less frequent dosing. In Coady’s opinion, such a vaginally localized plan doesn’t necessitate a urine, saliva, or blood test.
Next month: Part 2, Hormones, Menopause and Vaginal Atrophy: Paths to Self-Advocacy at https://www.empowher.com/menopause/content/hormones-menopause-and-vaginal-atrophy-paths-self-advocacy
Sources:
Risks and benefits of estrogen plus progestin in healthy postmenopausal women
http://works.bepress.com/ockenej/164
Interview with Dr. Cheryl Perlis, July 26, 2012
Interview with Dr. Deborah Coady, July 26, 2012
Interview with Dr. Alyssa Dweck, July 26, 2012
Reviewed July 30, 2012
by Michele Blacksberg RN
Edited by Jody Smith