Re: Is vaginal estrogen unnaposed?
From: Joanne Bulley, MD (islesannie@gmail.com)
Wed Feb 25 19:06:49 2009
One of last year's ABOG articles was on Vagifem (25mcg QD X 2 weeks
followed by 25mcg twice weekly).
Endometrial biopsy done at start and at 1 year. I recall one case of
endometrial hperplasia at start - no treatment and 0 cases of any
abnormality of endometrium at 1 year. Conclusion : that dose (eg
Vagifem and by similarity Estring) does NOT need any progestin
protection of endometrium.
I have not looked at the package insert recently - but recall from >/10 years ago: serum estradiol "peaked" at a a very low level in those
first 2-4 weeks then dropped to marginally higher than negligible.
As far as the estrace or premarin cream: *I think* but could be wrong
that the cream facilitates some of the absorption.
However, when I use topical estrogen for atrophy: the problem nearly
100% appears to be introital as the site that creates symptoms - so why
use it in the upper vagina with the applicator that no one wants to wash
anyway?
I treat with Estrace cream only (use 17-Beta-Estradiol because that is
the molecule the ovary/granulosa cells make and the vaginal epithelium
has the receptors for). Why use Premarin with the various equine
estrogens - some of which are not metabolized by human enzymes?
I have the woman use - massage in - twice daily X 2 weeks, once daily
"until function is normalized" then 1-3 times a week til feels good
enough that she forgets to use it. Total exposure is minimal.
I did have one woman call and say she had horrible breast tenderness
after a few weeks --- turns out she was using a full applicator (4 gms?)
daily! Her vaginal atrophy symptoms were 100% resolved. I had her stop
use, come in and again I instructed her carefully that she should have
been using a "pea to lima bean" size dose of the Estrace! Anymore I
usually give a sample tube - and tel them to watch me THROW out the
applicator - very expilicit instructions!
Joanne
At Wed, 25 Feb 2009, Rafael Haciski wrote:
>
>Vaginal absorption is excellent, but variable. When I need to push to
>the limit, I will monitor with serum E2 levels. As long as levels are
>low I am not concerned about uterine stimulation.
>
>1 gm twice weekly will not do much to the levels. If I need a bigger
>bang, I may push to as much as daily, but then watch levels. If high,
>drop down.
>
>Sent from my iPhone
>
>On Feb 25, 2009, at 18:02, Ronald Ainsworth <ainsron@sbcglobal.net>
>wrote:
>
>> I had always heard the same thing Art said, decreased absorption as
>> the epithelium matures.
>>
>> --- On Wed, 2/25/09, Richard Chudacoff <rchudacoff@mylinuxisp.com>
>> wrote:
>>
>>> From: Richard Chudacoff <rchudacoff@mylinuxisp.com>
>>> Subject: RE: Is vaginal estrogen unnaposed?
>>> To: "Multiple recipients of list OB-GYN-L" <ob-gyn-l@mail.obgyn.net>
>>> Date: Wednesday, February 25, 2009, 1:20 PM
>>> I always thought it was the other way around; as the
>>> epithelium thickens,
>>> there is an increase in vascularization, which increases
>>> the absorption
>>>
>>> Richard Chudacoff, MD, FACOG
>>>
>>> -----Original Message-----
>>> From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On
>>> Behalf Of art
>>> fougner, md
>>> Sent: Wednesday, February 25, 2009 12:25 PM
>>> To: Multiple recipients of list OB-GYN-L
>>> Subject: Re: Is vaginal estrogen unnaposed?
>>>
>>> Dan
>>>
>>> As the vaginal epithelium thickens in response to E cream,
>>> the
>>> absorption decreases a bit ... an interesting feedback
>>> loop.
>>>
>>> Art
>>>
>>> At Wed, 25 Feb 2009, R. Daniel Braun wrote:
>>>>
>>>> --000e0cd4872e1edd6a0463c3d788
>>>> Content-Type: text/plain; charset=windows-1252
>>>> Content-Transfer-Encoding: quoted-printable
>>>>
>>>> On Wed, Feb 25, 2009 at 11:07 AM, Christopher Jones
>>> <christopj@msn.com>wrote:
>>>>
>>>>> I just diagnosed a postmenopausal woman with
>>> endometrial adenocarcinoma.
>>>>> Her only identifiable risk factor, if any, is a
>>> history of premarin
>>>>> cream unnaposed by progestins.
>>>>>
>>>>> My question is
>>>>>
>>>>> 1. Do you consider giving local estrogen without
>>> progestins unnaposed?
>>>>
>>>> NO
>>>>
>>>> However, I wouldn't give vaginal estrogen to
>>> someone who shouldn't take
>>>> oral. The vaginal cream gets absorbed and enters the
>>> blood stream and the
>>>> doseage isn't controlled as well as it is with
>>> oral.
>>>>
>>>>> 2. In your patients on local estrogen for
>>> vulvovaginal symptoms, if you
>>>>> give a progestin what is your protocol?
>>>>>
>>>>> Thanks
>>>>>
>>>>> Chris
>>>>>
>>>> --
>>>> R. Daniel Braun, MD FACOG(L) ABMP CMTh
>>>> Professor Emeritus
>>>> Dept. of Obstetrics and Gynecology
>>>> Indiana U. School of Medicine
>>>>
>>>> --
>>>> R. Daniel Braun
>>>>
>>>> ¡°Science without Religion is LAME; Religion
>>> without Science is BLIND"
>>>> Einstein 1941
>>>>
>>>> --000e0cd4872e1edd6a0463c3d788
>>>> Content-Type: text/html; charset=windows-1252
>>>> Content-Transfer-Encoding: quoted-printable
>>>>
>>>> <br><br><div
>>> class="gmail_quote">On Wed, Feb 25, 2009 at
>>> 11:07 AM,
>>> Christopher Jones <span dir="ltr"><<a
>>> href="mailto:christopj@msn.com">christopj@msn.com</a>></span>
>>> wrote:<br><blockquote
>>> class="gmail_quote" style="border-left: 1px
>>> solid
>>> rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex;
>>> padding-left: 1ex;">
>>>> I just diagnosed a postmenopausal woman with
>>> endometrial
>>> adenocarcinoma.<br>
>>>>
>>>> Her only identifiable risk factor, if any, is a history
>>> of premarin<br>
>>>> cream unnaposed by progestins.<br>
>>>> <br>
>>>> My question is<br>
>>>> <br>
>>>> 1. Do you consider giving local estrogen without
>>> progestins
>>> unnaposed?</blockquote><div><br><br><br>NO<br><br>However,
>>> I wouldn't give
>>> vaginal estrogen to someone who shouldn't take oral.
>>> The vaginal cream gets
>>> absorbed and enters the blood stream and the doseage
>>> isn't controlled as
>>> well as it is with oral.<br>
>>>> <br> <br></div><blockquote
>>> class="gmail_quote" style="border-left: 1px
>>> solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex;
>>> padding-left:
>>> 1ex;"><br>
>>>> 2. In your patients on local estrogen for
>>> vulvovaginal symptoms, if
>>> you<br>
>>>> give a progestin what is your protocol?<br>
>>>> <br>
>>>> Thanks<br>
>>>> <br>
>>>> Chris<br>
>>>> <br>
>>>> </blockquote></div><br>
>>>> FACOG(L) ABMP CMTh<br>Professor
>>> Emeritus<br>Dept. of Obstetrics and
>>> Gynecology<br>Indiana U. School of
>>> Medicine<br><br><br>R. Daniel
>>> Braun<br><br> ¡°Science without
>>> Religion is LAME; Religion without
>>> Science is BLIND"<br>
>>>> Einstein
>>> 1941<br>
>>>>
>>>> --000e0cd4872e1edd6a0463c3d788--
>>>>
>>> --
>>> art fougner, md
>>> "May The Wings of Liberty Never Lose a Feather."
>>> - Jack Burton
--
Joanne Bulley, MD
solo gyn
Keene, NH
