Is vaginal estrogen right for me?
What feelings arise when you hear vaginal estrogen? Is it
1. “OMG taking hormones? Absolutely not.”
2. “Uhh.. I have no idea what that even means?”
3. Or a 3rd option of “Heck yeahh!!”
If you responded like numbers 1 or 2, let us explain what vaginal estrogen really is, how it differs from systemic oral estrogen, what it helps treat, and how it relates to us over here at Hey Babe as Pelvic PTs. If you’re number 3, girl same!
Why are we talking about vaginal estrogen in pelvic PT?
The muscles of the pelvic floor, specifically, are affected by the regular somatic nervous system that controls all of our muscles- ie our biceps, hamstrings, etc. But it is also governed by our autonomic nervous system, the one that controls things such as digestion, breathing, heartbeat, etc. The pelvic floor is incredibly sensitive to hormone balance because of its direct connection to the reproductive system.
There are *so many* estrogen receptors in vaginal tissue due to its developmental properties. At times when estrogen is compromised (we’ll discuss below), symptoms around the pelvic floor can arise or worsen. Low local vaginal estrogen can impact vaginal tissue directly and show up as:
- Vaginal dryness
- Vaginal itching
- Vaginal burning
- Vulvodynia/ Vestibulodynia
- Bacterial vaginosis
- Yeast infections
- Frequent UTI’s
- Urinary incontinence
- Painful sex or bleeding after intercourse
- Decreased lubrication
- Shortening and tightening of the vaginal canal
Multiple studies have shown that topical estrogen is a valid treatment for these symptoms. It comes in the form of estradiol- the form of estrogen that naturally occurs in our bodies. The one we usually recommend is FDA approved and guess what? It’s derived from sweet potatoes! (Yes, SWEET POTATOES). The main ones come in either cream or suppository form.Both have been shown to be highly effective.
How is topical estrogen different than just taking an oral pill?
In the standard form of topical estrogen used, the concentration of estrogen is only 10 micrograms, meaning the annual dose of using topical estrogen is slightly more than 1 milligram. Typical oral estrogen tablets (in the form of esterase) are 0.5 milligrams in each dose. This means that topical estrogen is only equivalent to two esterase pills for a year supply.
Not only is the amount of estrogen exposure extremely low in topical estrogen, but studies also suggest that the blood serum concentration from topical estrogen is negligible- meaning that it does not pass into the bloodstream to lead to any other systemic effects. So just be aware, taking oral estrogen comes with the potential risk of certain cancers and cardiovascular events.
Who does it affect?
Menopause is the process in which women’s reproductive hormones naturally decline. Studies show that 50% of women going through menopause will experience vaginal dryness and sexual discomfort. Up to 1/3 also experience itching, painful sex, and atrophic vaginitis (shrinking of the tissue).
Estradiol is a topical solution to this problem. It has been shown to dramatically improve vaginal symptoms, decrease UTIs, and even decrease incontinence. It can also act to normalize vaginal pH changes that can occur with decreased estrogen that can lead to bacterial vaginosis or yeast infections.
Being postpartum is a similar experience to going through menopause. Immediately, once you are postpartum your estrogen levels plummet. Believe it or not, it can take up to 2 years for hormones to fully normalize again. Vaginal atrophy (muscle wasting and tissue thinning), dryness, pelvic pain, and pH changes are just a few common symptoms. These symptoms are more likely to occur when breastfeeding due to its association with low estrogen.
Various studies suggest that topical estradiol can improve overall vaginal symptoms postpartum. Because blood serum estrogen does not increase, it is also safe for breastfeeding mothers and babies. Win-win! Some studies also suggest that there is no effect on milk supply, which is a big concern for new mothers. Luckily, topical estrogen is safe for all mothers, even those breastfeeding!
3. Vestibulodynia/ Vulvodynia
Vestibulodynia and vulvodynia are chronic pain conditions that occur in the areas around the opening of the vagina and vulva, respectively. This can occur as a side effect of taking SSRIs, SNRIs, or hormonal birth control. As mentioned before, there are estrogen receptors in the vulva. When topical estrogen is applied in the area, it can plump the tissue back up and eliminate pain and discomfort.
But if you don’t prescribe it, where do I get it?
If you feel like topical estrogen is calling your name after reading this article, then you should speak to your doctor. If your doctor has a 3-month waitlist like mine, you can go through the new women's telehealth platform - Odela - to speak to a practitioner via Zoom and get a 3-month supply. (Note: it usually takes 2-3 months to see results).
A warning: there is a big fat FDA black box when you get the prescription that says that vaginal estrogen will increase your risk for the same things oral estrogen will (cardiovascular events, certain cancers, etc.) Practicing pelvic healthcare workers are trying incredibly hard to get this removed because the studies actually don’t support it. In other countries like the UK, you can find vaginal estrogen over the counter - that’s how safe it really is!
The best results for the conditions listed above also include seeing a pelvic PT. Pelvic pain, irritation, and dryness can lead to pelvic floor spasm and weakness (or vice versa). So don’t forget to give us a call if you feel like your symptoms go beyond just topical treatment! And as always, if you have more questions, never hesitate to reach out 😊
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