Topical Estrogen

Menopause:

Menopause (e.g., the complete or permanent stopping of menstruation) is associated with the loss of estrogen which affects the pelvic organs and lower urinary tract. Estrogen receptors are found in the vagina, urethra, and bladder. When your estrogen hormone levels drop, the tissues in these organs start to weaken causing a condition called "urogenital atrophy." You may experience symptoms such as urinary urgency, frequency, painful intercourse, burning when urinating, vaginal dryness, itching, and vaginal discharge. This loss of estrogen may make you more susceptible to bladder infections and urinary incontinence. It may also cause your pelvic organs, bladder, uterus, and rectum to sag or fall. This is called "prolapse."

Can estrogen help urinary incontinence, urinary urgency, frequency, and urinary tract infections?

Estrogen may help improve urinary incontinence and overactive bladder symptoms, e.g., urinary urgency, frequency, and nocturia (getting up more than once per night).

Estrogen may help to strengthen the tissues providing support to the pelvic organs. It also helps to decrease dryness and thinning of the tissues which may help to increase their resistance to infection as well as decrease their irritability. Oral estrogens (pills) are typically avoided in the treatment of urinary incontinence and overactive bladder because of they have not been shown to be effective. However, topical estrogen has gained increasing attention for its possible role in managing these two syndromes. It has also been shown to help prevent urinary tract infection in the woman who is at risk for these infections.

Topical estrogen (vaginal cream, tablet, or ring) is considered a safer and more effective method of delivering estrogen to the pelvic organs than oral estrogen because it uses a lower dose of estrogen; specifically targets the delivery of estrogen to the vagina and lower urinary tract; and generally avoids getting distributed throughout the body. Oral estrogen therapy (pills) circulates estrogen throughout the body in the blood stream but may not reach a high enough concentration to affect the lower urinary tract.

How to use topical estrogens:

Wash your hands with soap and water, and dry them.

To use the vaginal cream (the cream is called "Estrace" or "Premarin"):

• You can use the applicator that comes with the cream. Or you can squeeze some cream to cover your fingertip by squeezing the tube to express out 1 gram of cream (about enough to cover 1/2 of your index finger).
• Locate the opening to your vagina. Carefully spread the cream onto the external vaginal/urethral area. As the cream is spread, some should be gently inserted into the vagina.
• You should use the cream every night for 10 days, then 3 times per week.

To use the vaginal tablet (the tablets are called "Vagifem"):

• You can insert the tablet either lying down or standing with your foot raised onto a stool.
• Hold the applicator so that the finger of one hand can press the applicator plunge.
• The other hand should be used to guide the application gently and comfortably through the vaginal opening.
• One-half of the applicator should be put inside your vagina
• Do not force the applicator into your vagina, but gently press the plunger until it is fully depressed and the tablet will be ejected.

To use the vaginal ring (this is called the "Estring" or "Femring"):

• You can insert the Estring either lying down or standing with your foot raised onto a stool. The exact position is not important as long as you don't feel the ring. If you do, it may not be inserted far enough into the vagina.
• If the ring slips, just push it back up with your fingers.
• If the ring falls out, rinse it with warm water and reinsert it.
• Each Estring is left in place for 3 months. When replacing the Estring, hook your finger around it and pull it out. Then insert a new Estring.
• If a vaginal infection is present, the Estring should be removed until after the infection clears.

Who should avoid using topical estrogen?

Women who have had breast or uterine cancer, unusual vaginal bleeding, a history of blood clots, are pregnant or think they are pregnant, have just had a child, or are breast-feeding should not use topical estrogen. Topical estrogen should be used with caution in women who have liver disease.

What side effects can be expected?

Side effects tend to be mild. They include: vaginal spotting, vaginal discharge, vaginal itching, allergic reactions, and skin rash. Other side effects include: headache, back pain, abdominal pain, and vaginal yeast infections

If you experience any of the following symptoms, contact your primary care provider immediately:

• Abdominal pain, tenderness, or swelling
• Abnormal vaginal bleeding
• Breast lumps
• Coughing up blood
• Difficulty with speech
• Dizziness or faintness
• Pain in your chest or calves
• Severe headache or vomiting
• Sudden shortness of breath
• Vision changes
• Weakness or numbness of an arm or leg

Adapted from: Newman, D.K. (2002). Managing and treating urinary incontinence. Baltimore: Health Professions Press. Used with permission from Diane K. Newman, MSN, APRN-BC, FAAN.